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Home My WebLink About05-0156 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA DENNIS and DIXIE WALK, individually and as parents and natural guardians of CHELSEY WALK, a minor 120 Dudley Road Six Mile Run, Pennsylvania 16679 Civil Action - Law Plaintiffs v. Nof)~- l(l~ Civil Term MICHELE BLEVINS 709 Phoenix Avenue Fruitland Park, Florida 34731 Jury Trial Demanded and FREDERICK D. RICE 801 Myerstown Road Gardners, Pennsylvania 17324 Defendant NOTICE TO DEFEND You have been sued in court. If you wish to defend against the claims set forth against you in the following pages, you must take action within twenty (20) days after this Complaint and Notice are served, by entering a written appearance personally or by attorney and filing in writing with the Court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a default judgment may be entered against you by the Court without further notice for any money claimed in the Complaint or for any other claim or relief requested by the Plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. Court Administrator 4th Floor, Cumberland County Courthouse Carlisle, Pennsylvania 17013 Telephone No. (717) 240-6200 AVISO Usted Ha Sido Demandado en la corte. Si usted desea defenderse de las quejas expuestas en las paginas siguientes, debe tomar accion dentro de veinte (20) dias a partir de la fecha en que recibio la demanda y el aviso. Usted debe presentar comparecencia escrita en persona 0 por abogado y presentar en la Corte por escrito sus defensas 0 sus objeciones alas demandas en su contra. Se Ie avisa que si no se defiende, el caso puede proceder sin usted y la corte puede decidir en su contra sin mas aviso 0 notificacion por cualquier dinero reclamado en la demanda 0 por cualiquier otra queja 0 compensacion reclamados por el Demandante. Usted puede perder dinero, 0 propiedades u otros derechos importantes para usted. USTED DEBE LLEVAR ESTE DOCUMENTO A SU ABOGADO INMEDIATAMENTE. SI USTED NO TIENE UN ABOGADO, LLAME 0 VAYA A LA SIGUIENTE OFICINA. EST A OFICINA PUEDE PROVEERLE INFORMACION A CERCA DE COMO CONSEGUIR UN ABOGADO. SI USTED NO PUEDE PAGAR POR LOS SERVICIOS DE UN ABOGADO, ES POSIBLE QUE ESTA OFICINA LE PUEDA PROVEER INFORMACION SOBRE AGENCIAS QUE OFREZCAN SERVICIOS LEGALES SIN CARGO 0 BAJO COSTO A PERSONAS QUE CUALlFICAN. Court Administrator 4th Floor, Cumberland County Courthouse Carlisle, Pennsylvania 17013 Telephone No. (717) 240-6200 MARTZ & GAILEY LLP Date: I (S/ (J5 41--1f 6 ~ r-> Herman A. Gailey, III, Esquire 96 South George Street Suite 430 York, PA 17401 (717) 852-8379 10 No.: 31097 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA DENNIS and DIXIE WALK, individually and as parents and natural guardians of CHELSEY WALK, a minor 120 Dudley Road Six Mile Run, Pennsylvania 16679 Civil Action - Law Plaintiffs vi. NO.(J.\ - Civil Term MICHELE BLEVINS 709 Phoenix Avenue Fruitland Park, Florida 34731 Jury Trial Demanded and FREDERICK D. RICE 801 Myerstown Road Gardners, Pennsylvania 17324 Defendant AND NOW, this COMPLAINT l5~ day of January, 2005, come the Plaintiffs, Dixie and Dennis Walk, individually and as parents and natural guardians of Chelsey Walk, a minor, by their attorney, Herman A. Gailey, III, and file the following Complaint: 1. Plaintiffs, Dixie and Dennis Walk, are adult individuals, husband and wife, currently residing at 120 Dudley Road in Six Mile Run, Bedford County, Pennsylvania. 2. Plaintiffs, Dixie and Dennis Walk, are the parents and natural guardians of Plaintiff, Chelsey Walk, a minor. 3. Defendant, Michele Blevins, is an adult individual currently residing at 709 Phoenix Avenue, Fruitland Park, Florida 34731. 4. Defendant, Frederick Rice, is an adult individual currently residing at 801 Myerstown Road, Gardners, Adams County, Pennsylvania 17324. 5. On June 19, 2003, Defendant, Michele Blevins, was the owner and operator of a 1999 Honda Accord, traveling northbound on Carlisle Road at or near its intersection with Pine Grove Road in Dickinson Township, Cumberland County, Pennsylvania. 6. At that time, Plaintiff, minor Chelsey Walk, was a backseat passenger in Defendant, Michele Blevins' vehicle. 7. At that same time, Defendant, Frederick Rice, was the operator of a 1992 Chevrolet 2500, which was owned by Loretta Rice, traveling eastbound on Pine Grove Road, approaching its intersection with Carlisle Road in Dickinson Township, Cumberland County, Pennsylvania. 8. At that time, the intersection of Carlisle Road and Pine Grove Road in Dickinson Township, Cumberland County, Pennsylvania, was governed by a stop sign for motorists traveling on Pine Grove Road. 9. At that time, Defendant, Frederick Rice, failed to stop for the stop sign and entered said intersection. 10. As Defendant, Michele Blevins, was entering said intersection, she swerved to the right to avoid striking Defendant, Frederick Rice's vehicle as it entered Carlisle Road. 11. Defendant, Michele Blevins, lost control of her vehicle, struck a stop sign, and ran into a stone wall, causing a collision and personal injuries to Plaintiff, Chelsey Walk. 12. The accident and injuries hereinafter set forth were caused by the negligence of Defendants and were in no way due to any act or failure to act on the part of the Plaintiffs. COUNT I DIXIE AND DENNIS WALK, as parents of Chelsey Walk, a minor v. MICHELE BLEVINS 13. Paragraphs one through twelve (1-12) are incorporated herein by reference as if fully set forth at length. 14. Defendant, Michele Blevins, was negligent in the following manner: a. Carelessly operating her vehicle in violation of 75 Pa.C.S.A. 93714; b. Recklessly driving a vehicle in violation of 75 Pa.C.S.A. 93736; c. Operating her vehicle at an unsafe speed under the circumstances in violation of 75 Pa.C.S.A. 93361; d. Failing to keep alert and maintain a proper lookout for other traffic in violation of 75 Pa.C.S.A. 93321; and e. Failing to maintain control of her vehicle in violation of 75 Pa.C.S.A.93321. 15. As a result of the accident, Plaintiff, Chelsey Walk, has sustained serious injuries which include, but are not limited to a grade IV liver laceration and post-traumatic anxiety. 16. As a further result of the accident, Plaintiff, Chelsey Walk, has sustained or may sustain the following damages: a. Past and future pain and suffering; b. Past and future embarrassment, humiliation, and mental anxiety; c. Past and future loss of life's enjoyment; d. Past and future incident costs; e. Past and future reasonable and necessary medical expenses in excess of the statutory preclusion; f. Past and future loss of earnings in excess of first-party benefits; and g. Scarring and disfigurement. 17. Plaintiffs aver that Chelsey Walk's damages exceed the applicable limits of arbitration, therefore, a jury trial is hereby demanded. WHEREFORE, Plaintiffs, Dixie and Dennis Walk, as parents and natural guardians of Chelsey Walk, a minor, respectfully request that this Honorable Court enter judgment against Defendant, Michele Blevins, for damages in an amount in excess of $25,000.00, plus interest and costs as permitted by law. COUNT II DIXIE AND DENNIS WALK, individually v. MICHELE BLEVINS 18. Paragraphs one through seventeen (1-17) are incorporated herein by reference as if fully set forth at length. 19. As a result of the injuries and damages sustained by their daughter, Chelsey Walk, caused by the negligence of Defendant, Michele Blevins, Plaintiffs, Dixie and Dennis Walk were required to expend monies for their daughter's care and treatment. 20. Plaintiffs aver that their damages exceed the applicable limits of arbitration, therefore, a jury trial is hereby demanded. WHEREFORE, Plaintiffs, Dixie and Dennis Walk, respectfully request that this Honorable Court enter judgment against Defendant, Michele Blevins, for damages in an amount in excess of $25,000.00, plus interest and costs as permitted by law. COUNT III DIXIE AND DENNIS WALK, as parents of Chelsey Walk, a minor v. FREDERICK RICE 21. Paragraphs one through twenty (1-20) are incorporated herein by reference as if fully set forth at length. 22. Defendant, Frederick Rice, was negligent in the following manner: a. Carelessly operating a vehicle in violation of 75 Pa.C.S.A. 93714; b. Recklessly driving a vehicle in violation of 75 Pa.C.S.A. 93736; c. Failing to obey a traffic control device in violation of 75 Pa.C.S.A. 93323; d. Operating a vehicle at an unsafe speed under the circumstances in violation of 75 Pa.C.S.A. 93361; e. Failing to keep alert and maintain a proper lookout for other traffic in violation of 75 Pa.C.S.A. 93321; and f. Failing to yield the right-of-way to oncoming traffic in violation of 75 Pa.C.S.A. 93324. 23. As a result of the accident, Plaintiff, Chelsey Walk, has sustained serious injuries which include, but are not limited to a grade IV liver laceration and post-traumatic anxiety. 24. As a further result of the accident, Plaintiff, Chelsey Walk, has sustained or may sustain the following damages: a. Past and future pain and suffering; b. Past and future embarrassment, humiliation, and mental anxiety; c. Past and future loss of life's enjoyment; d. Past and future incident costs; e. Past and future reasonable and necessary medical expenses in excess of the statutory preclusion; f. Past and future loss of earnings in excess of first-party benefits; and g. Scarring and disfigurement. 25. Plaintiffs aver that Chelsey Walk's damages exceed the applicable limits of arbitration, therefore, a jury trial is hereby demanded. WHEREFORE, Plaintiffs, Dixie and Dennis Walk, as parents and natural guardians of Chelsey Walk, a minor, respectfully request that this Honorable Court enter judgment against Defendant, Frederick Rice, for damages in an amount in excess of $25,000.00, plus interest and costs as permitted by law. COUNT IV DIXIE AND DENNIS WALK, individually v. FREDERICK RICE 26. Paragraphs one through twenty-five (1-25) are incorporated herein by reference as if fully set forth at length. 27. As a result of the injuries and damages sustained by their daughter, Chelsey Walk, caused by the negligence of Defendant, Frederick Rice, Plaintiffs, Dixie and Dennis Walk were required to expend monies for their daughter's care and treatment. 28. Plaintiffs aver that their damages exceed the applicable limits of arbitration, therefore, a jury trial is hereby demanded. ~ WHEREFORE, Plaintiffs, Dixie and Dennis Walk, respectfully request that this Honorable Court enter judgment against Defendant, Frederick Rice, for damages in an amount in excess of $25,000.00, plus interest and costs as permitted by law. Respectfully submitted, ?1-A ~cJf; l Herman A. Gailey, III, Esquire MARTZ & GAl LEY LLP 96 South George Street Suite 430 York, PA 17401 (717) 852-8379 10 No.: 31097 VERIFICATION I, DENNIS WALK, do hereby verify that the facts set forth in the foregoing Complaint are true to the best of my knowledge, information and belief. I understand that false statements made herein are made subject to the penalties of the 18 Pa. C.S.A. 94904 relating to unsworn falsification to authorities. /Qi1c/Jt~ Wdk D@jNIS WALK Date: (JI d9'. ot{ VERI FICA TION I, DIXIE WALK, do hereby verify that the facts set forth in the foregoing Complaint are true to the best of my knowledge, information and belief. I understand that false statements made herein are made subject to the penalties of the 18 Pa. C.S.A. S 4904 relating to unsworn falsification to authorities. . /l;LJ t ~)~ DIXfE~~K Date: l"2/~C) /0 LJ- ~ (:) -'<l ,....., ~ CI) n (-? 0 c:: c:.:l -n cfl U) ~' ~ 1 '- ;rfl rnfD Z "- €I) -ry rI ~ ~ :'JQ C> 0 ~~J. ~~~ w W pc! ~ r - :~!,~ .,,-- ~ - , ;-" ~.. \...0 ...../ --1 ;;'-'~ ~ ~ --{ en ";:) -< -I .< "-'-. DENNIS and DIXIE WALK, IN THE COURT OF COMMON PLEAS Individually and as Parents and Natural CUMBERLAND COUNTY, PENNSYLVANIA Guardians of CHELSEY WALK, a minor,: Plaintiffs vs. NO. 2005-156 CIVIL TERM MICHELE BLEVINS and FREDERICK D. RICE, JURY TRIAL DEMANDED Defendants CIVIL ACTION - LAW PRAECIPE FOR ENTRY OF APPEARANCE TO THE PROTHONOTARY: Please enter the undersigned's appearance on behalf of the Defendant, MICHELE BLEVINS, with regard to the above-captioned matter. Respectfully submitted, NEALON, GOVER & PERRY Date: ~ By:ll{ll~(;~cr Michael S. Ferguson, Esquire 1.0, No, 83882 2411 North Front Street Harrisburg, PA 17110 717/232-9900 CERTIFICATE OF SERVICE AND NOW, this \ (Vday of March, 2005, I hereby certify that I have served the foregoing PRAECIPE FOR ENTRY OF APPEARANCE on the following by depositing a true and correct copy of same in the United States mail, postage prepaid, addressed to: Herman A. Gailey, III, Esquire MARTZ & GAILEY LLP 96 South George Street, Suite 430 York, PA 17401 Frederick D. Rice 801 Myerstown Road Gardners, PA 17324 lLGL&ltq- Michael S, Ferguson, Esquire SHERIFF'S RETURN - U.S. CERTIFIED MAIL CASE NO: 2005-00156 P COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND WALK DENNIS ET AL VS. BLEVINS MICHELE ET AL R. Thomas Kline Sheriff of Cumberland County, Pennsylvania, who being duly sworn according to law served the within named DEFENDANT ,BLEVINS MICHELE by United States Certified Mail postage prepaid, on the 11th day of January ,2005 at 1200:00 HOURS, at 709 PHOENIX AVENUE FRUITLAND PARK, FL 34731 I a true and attested copy of the attached COMPLAINT & NOTICE Together with The returned receipt card was signed by MICHELE M BLEVINS 01/14/2005 on Additional Comments: Sheriff's Costs: So answe'r's: Docketing Service Affidavit Surcharge 18.00 4.88 .00 10.00 .00 32.88 ~J ~ -~ R. Thomas Kline Sheriff of Cumberland County Paid by MARTZ & GAILEY on 01/20/2005 . Sworn and subscrib~d to before me this ;i'/.L:: day OfLh~i ~~, A.D. / "-but" () nll,;PJu ~ pio honotary , SHERIFF'S RETURN - OUT OF COUNTY CASE NO: 2005-00156 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND WALK DENNIS ET AL VS BLEVINS MICHELE ET AL R. Thomas Kline , Sheriff or Deputy Sheriff who being duly sworn according to law, says, that he made a diligent search and and inquiry for the within named DEFENDANT f to wit: RICE FREDERICK D but was unable to locate Him in his bailiwick. He therefore deputized the sheriff of ADAMS County, Pennsylvania, to serve the within COMPLAINT & NOTICE On January 20th , 2005 , this office was in receipt of the attached return from ADAMS Sheriff's Costs: Docketing Out of County Surcharge Dep Adams County So answers: 6.00 9.00 10.00 30.24 .00 55.24 01/20/2005 MARTZ & GAILEY .-".---;77 e' -Z. R. Thomas Kline Sheriff of Cumberland County Sworn and subscribed to before me this .li~ day ofc)""~7 ~V/)., A,D. 0~'~prtdht~!t~~, ~ In The Court of Common Pleas of Cumberland County, Pennsylvania Dennis Walk et al VS. Michele Blevins et al SERVE: Frederick D. Rice No. 05-156 civil Now, January 10, 2005 , I, SHERIFF OF CUMBERLAND COUNTY, P A, do hereby deputize the Sheriff of Adams County to execute this Writ, this deputation being made at the request and risk of the Plaintiff. a -^;" .., <" r; / </. ,0'/'. ~-:::.. ~-"''''''.,~~I.<._.' .... ~ ~7~<-,;t!1::,...."Jt~ ,('" ,~_""..._,~~ _.<7 ,." '" '"/' "......,'~,__". .-"1> Sheriff of Cumberland County, P A Affidavit of Service Now, January 18 , 20~, at 8:30 o'clock P. M. served the within Complaint in Civil Action upon Frederick D. Rice at 801 Myerstown Road, Gardners, PA by handing to Carrie Rice, adult in charge of residence at time of service a true and attested copy of the original complaint and rnade known to Carrie Rice the contents thereof. So answers, Dep County, PA ,./ Sworn and subscribed before me this _ day of N/A ,20 COSTS SERVICE MILEAGE AFFIDA VlT $ 18.00 12.24 $ 30.24 " '6 Ii . C- o ~ :;; :>. 0 :g ~ 0- -,:: "$ " ~o ~ It .. ~ c . . ~"3q u.. o..'aiO \1 ~t<0 & 000 0' ~ :a @ .J< " \\) ~ ~ 'Z. 0 0.'0 'iii-c "% ?'~~~ .9 ~~~~ \i, <- 0 n:-- ~~OO It .; ~ ~ _ 4i '9- 0- . ~ .'~ %~~6E o''J)~ >otII o CD C.s~ . $~O-oO~ .c_ '" "'~ S I!i (:''& 0 0 Q; ~'!?~<l)~0- c.c, "'O.s CD tl;\Q)roc~~ cJO"O '5..... 0.. ..-=ifi~"'roSt1l .......(\)>--"'O~ €.gE~'mC Q)jjjt'iSOOe ~Q)C<l)l1l- S~~~'~2 t."q ~~f>~ E~"C:S~O o~.-o~'- 0~o:.lf)4:.0 . . '" N o "' m w M ...." , If) o .... f"l r- .. f"l (l)~ a ~~;2 ....;0: \;\ ~>l.p. ~.;.I t:!lm~ (l)2~ ~p.~ fl ",'~ .;.10 $r- "9- i ~ 3 It o ~ % o '" nJ r- f\.\ r- Cl r- d) Cl " o Cl Cl Cl .n f\.\ f\.\ '" Cl Cl r- ~ ~ ,;; ~ a. o .. - - - - o OOc J>-Z.,. ;:orn".. '-00:1 -Om ~c:~ rn:o,. '-'z "0:]:0 J>-gC") ~U'>o --.jrnc: CJU'>z Z;;p~ C:<J> ?P::a: ""g; ::n -n (ii "" rn -0 a l - - - - -- - -- . ,-- . DENNIS and DIXIE WALK, Individually and as Parents and Natural Guardians of CHELSEY WALK, a minor,: Plaintiffs IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA vs, NO. 2005-156 CIVIL TERM MICHELE BLEVINS and FREDERICK D, RICE, Defendants JURY TRIAL DEMANDED CIVIL ACTION - LAW NOTICE TO PLEAD TO: Dennis and Dixie Walk Individually and as Parents And Natural Guardians of Chelsey Walk, a minor C/o Herman A. Gailey, III, Esquire MARTZ & GAILEY LLP 96 South George Street, Suite 430 York, PA 17401 YOU ARE HEREBY NOTIFIED that the Answer to Complaint set forth herein contains averments against you to which you are required to respond within twenty (20) days after service thereof, Failure by you to do so may constitute an admission, Respectfully submitted, NEALON, GOVER & PERRY Date: L( It c{ By: 1\;((R0.cbl.ur Michael S, Ferguson, Esquire 1.0, #: 83882 2411 North Front Street Harrisburg, PA 17110 717/232 -9900 DENNIS and DIXIE WALK, Individually and as Parents and Natural Guardians of CHELSEY WALK, a minor,: Plaintiffs IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA vs. NO. 2005-156 CIVIL TERM MICHELE BLEVINS and FREDERICK D. RICE, Defendants JURY TRIAL DEMANDED CIVIL ACTION - LAW ANSWER TO COMPLAINT WITH NEW MATTER AND CROSS-CLAIM PURSUANT TO 2252(d} 1. Admitted on information and belief. 2. Admitted on information and belief, 3, Admitted, 4, Admitted on information and belief. 5, Admitted. 6. Admitted. 7, Admitted, 8, Admitted. 9. Admitted. 10, Admitted. 11, Admitted in part, It is admitted that the Defendant, Michele Blevins, swerved her vehicle to avoid a direct collision with a vehicle being operated by co- Defendant, Frederick D. Rice, and at that point struck a stop sign and ran into a stone wall causing damage to her vehicle and injuries to the Plaintiff, 12, Denied pursuant to Pa, R.C,P, 1029(e). COUNT I DIXIE AND DENNIS WALK, as Parents of CHELSEY WALK, A Minor V. MICHELE BLEVINS 13. No responsive pleading is required. 14 -17. Denied pursuant to Pa. R.C,P, 1029(e), WHEREFORE, Defendant Michele Blevins, respectfully requests that this Honorable Court enter judgment in her favor and against Plaintiffs together with any costs permitted by law. COUNT II DIXIE AND DENNIS WALK, Individually V. MICHELE BLEVINS 18. No responsive pleading is required. 19 - 20. Denied pursuant to Pa. R.C,P, 1029(e), WHEREFORE, Defendant Michele Blevins, respectfully requests that this Honorable Court enter judgment in her favor and against Plaintiffs together with any costs permitted by law, COUNT /II DIXIE AND DENNIS WALK, as Parents of CHELSEY WALK, a Minor V. FREDERICK RICE 21 - 25. These averments are directed at someone other than the answering Defendant. If any averment is directed towards answering Defendant, it is denied pursuant to Pa. R.C.P, 1029(e), COUNT IV DIXIE AND DENNIS WALK, Individually V. FREDERICK RICE 26 - 28, These averments are directed at someone other than the answering Defendant. If any averment is directed towards answering Defendant, it is denied pursuant to Pa, R.C,P, 1029(e), NEW MATTER 29, Paragraphs 1 through 28 are incorporated hereby by reference thereto. 30, The Plaintiffs' claims may be barred in whole or in part by application of the Pennsylvania Motor Vehicle Financial Responsibility Act. WHEREFORE, Defendant Michele Blevins, respectfully requests that this Honorable Court enter judgment in her favor and against Plaintiffs together with any costs permitted by law, NEW MATTER IN THE FORM OF A CROSS-CLAIM DIRECTED AT DEFENDANT FREDERICK D. RICE PURSUANT TO PA. R.C.P. 2252(dl 31. Paragraphs 1 through 30 are incorporated herein by reference thereto, 32. Answering Defendant incorporates herein by reference thereto the averments contained in Plaintiffs' Complaint without admission or adoption. 33, If Plaintiff sustained the injuries/damages as alleged in the Plaintiffs' Complaint, which are denied, it is averred that the incident giving rise to the instant civil action was caused solely by the negligence, carelessness andlor recklessness of Frederick D. Rice and said Defendant Frederick D, Rice is liable over to the answering Defendant. 34. This cross-claim is filed to protect the rights of answering Defendant to contribution and/or indemnification. WHEREFORE, answering Defendant, Michele Blevins, respectfully requests judgment be entered in her favor and against all other parties, Respectfully submitted, NEALON, GOVER & PERRY Date: '-1/1, /05'" B;lUlLG~~, Michael S. Ferguson, Esquire Attorney 1.0, No, 83882 2411 North Front Street Harrisburg, PA 17110 717/232-9900 04/05/2005 09:17 352-787-4524 I1'JKES I~AR HE Pl\i;E 02 , I I i I I I VERIFICATION I , ! I I, MICHELE BLEVINS, verify that the statements made in the foregoing Answer wiJh New Matter and Cross-Claim Pursuant to 2252(d) are true and correct. I un~erstand that false statements herein are made subject to the penalties of 18 P~,C,S.A, s4904 relating to unsworn falsification to authorIties , I j I i D~' jj~ I~ I I i I , CERTIFICATE OF SERVICE AND NOW, this I r- day of April, 2005, I hereby certify that I have served the foregoing ANSWER TO COMPLAINT WITH NEW MATTER AND CROSS-CLAIM PURSUANT TO 2252(d) on the following by depositing a true and correct copy of same in the United States mail, postage prepaid, addressed to: Herman A. Gailey, III, Esquire MARTZ & GAILEY LLP 96 South George Street, Suite 430 York, PA 17401 Frederick D. Rice 801 Myerstown Road Gardners, PA 17324 1~'L Michael S, Ferguson, Esquire () ~'n ..-1 ..- (,;) .-,,", r~? ,;~~::" :.,(-. (,~ --------------- IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA DENNIS and DIXIE WALK, individually and as parents and natural guardians of CHELSEY WALK, a minor Plaintiffs Civil Action - Law v. No, 2005-156 Civil Term MICHELE BLEVINS And FREDERICK D. RICE Defendant Jury Trial Demanded REPLY TO NEW MATTER OF DEFENDANT BLEVINS AND NOW this B!! day of /JpAJ..J , 2005, come Plaintiffs through their attorney Herman A. Gailey, III and reply to New Matter of Defendant Blevins as follows: 29, Denied to the extent the paragraphs incorporated are inconsistent with the corresponding paragraphs of Plaintiffs' Complaint. 30. Admitted that the Pennsylvania Motor Vehicle Financial Responsibility Act applies to this case. The alleged effect of that act upon Plaintiffs' claim is denied as a conclusion of law to which no response is required. 31-34. These paragraphs are directed to a party other than Plaintiffs and as such no response is required by Plaintiffs, WHEREFORE, your Honorable Court is respectfully requested to dismiss the new matter of Defendant Blevins and to enter judgment as prayed in Plaintiffs' Complaint. Respectfully Submitted: MARTZ & GAilEY, llP D~ 10 ')JX)) I ~J-I! C{~ e Herman A, Gailey, III, Esquire 96 South George Street Suite 430 York, PA 17401 (717) 852-8379 1.0, Number: 31907 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA DENNIS and DIXIE WALK, individually and as parents and natural guardians of CHELSEY WALK, a minor Plaintiffs Civil Action - Law vii. No. 2005-156 Civil Term MICHELE BLEVINS And FREDERICK D. RICE Defendant Jury Trial Demanded VERIFICATION I, Herman A, Gailey, III, Esquire, do hereby verify that I am the Attorney of Record for the pleading party herein, and that the facts set forth in the foregoing pleading are true to the best of my knowledge, information and belief, upon information supplied, and the verification of the party cannot be obtained within the time allowed for filing of the pleading, I understand that false statements made herein are made subject to the penalties of the 18 Pa, C.SA 4904 relating to unsworn falsification to authorities, If the Complaint contains averments which are inconsistent in fact, after reasonable investigation, I have been unable to ascertain which of the inconsistent averments in the Complaint are true, but have knowledge or information sufficient to form a belief that one of them are true, Respectfully submitted: MARTZ & GAILEY LLP Date: 4>>-J (~ ).{r)j~ -?/-,4- 6~~ Herman A. Gailey, III, Esquire 96 South George Street Suite 430 York, Pennsylvania 17401 (717) 852-8379 1.0. Number: 31097 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA DENNIS and DIXIE WALK, individually and as parents and natural guardians of CHELSEY WALK, a minor Plaintiffs Civil Action - Law viii. No, 2005-156 Civil Term MICHELE BLEVINS And FREDERICK D, RICE Defendant Jury Trial Demanded CERTIFICATE OF SERVICE I hereby certify that I have this /9 -Ii day of tjpJi (t , 2005 served a true and correct copy of the foregoing Reply to New Matter of Defendants on the follOWing individual as set forth below by first class, United States pre-paid postage: Michael S. Ferguson, Esquire NEALON, GOVER & PERRY 2411 North Front Street Harrisburg, PA 17110 Respectfully submitted: Date: ~J 19 }[t)j- ~/ilr:4~ Herman A, Gailey, III, Esquire MARTZ & GAILEY, LLP 96 South George Street Suite 430 York, Pennsylvania 17401 (717) 852-8379 10 Number: 31097 ..,I _.- t.-, t.' ,.~, ,~~:~ ...-.1'1 (~ .'\1 .---< ::~; ,: ",) o r,,) C,n ..t~'- __.J .< IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA DENNIS and DIXIE WALK, individually and as parents and natural guardians of CHELSEY WALK, a minor Plaintiffs Civil Action - Law v. No, 2005-156 Civil Term MICHELE BLEVINS And FREDERICK 0, RICE Defendant Jury Trial Demanded PRAECIPE TO SUBSTITUTE VERIFICATION To the Prothonotary: Please substitute the Verification of Herman A. Gailey, III, Esquire, regarding the Reply to New Matter of Defendant Blevins in the above-captioned case with the Verification of Dennis Walk and Dixie Walk. Respectfully Submitted: MARTZ & GAILEY, LLP "yY\{L~ I-{ :JJX',-cj- Date: I '7/ ~ ~ ~ Herman A. alley, III, Esquire 96 South George Street Suite 430 York, PA 17401 (717) 852-8379 1.0. Number: 31907 RECEIVED APR 2 5 20115 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA DENNIS and DIXIE WALK, individually and as parents and natural guardians of CHELSEY WALK, a minor Plaintiffs Civil Action - Law VI. No, 2005-156 Civil Term MICHELE BLEVINS And FREDERICK D, RICE Defendant Jury Trial Demanded VERIFICATION We, DENNIS WALK and DIXIE WALK, do hereby verify that the facts set forth in the foregoing Reply to New Matter of Defendant Blevins are true to the best of our knowledge, information and belief. We understand that false statements made herein are made subject to the penalties of the 18 Pa, C.SA 4904 relating to unsworn falsification to authorities, If the Complaint contains averments which are inconsistent in fact, after reasonable investigation, we have been unable to ascertain which of the inconsistent . averments in the Complaint are true, but have knowledge or information sufficient to form a belief that one of them are true, , ! Date: Lj, )). uS jat/V}! /(1 kJctOJ( DENNIS WALK rC j t~ c l,-lco. 'l V2 DIXIE ALK Date: ttlL3/05 , IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA DENNIS and DIXIE WALK, individually and as parents and natural guardians of CHELSEY WALK, a minor Plaintiffs Civil Action - Law vi. No, 2005-156 Civil Term IMICHELE BLEVINS ~nd FREDERICK D. RICE Defendant Jury Trial Demanded CERTIFICATE OF SERVICE , ,1JL I hereby certify that I have this 1-/ day of J71~, 2005 served a true and correct copy of the foregoing Praecipe to Substitute Ver' cation on the following individual as set forth below by first class, United States pre-paid postage: Michael S. Ferguson, Esquire NEALON, GOVER & PERRY 2411 North Front Street Harrisburg, PA 17110 Respectfully submitted: Date: Jll1rt Ie) 4. ;}(J() s- ?j)( ~~ ('=> Herman A. Gailey, III, Esquire MARTZ & GAILEY, LLP 96 South George Street Suite 430 York, Pennsylvania 17401 (717) 852-8379 ID Number: 31097 .-' ,':>"' (~~, \ u: o ~., .-\ -~~ t::-.\ c.~~ u- ... . IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA DENNIS and DIXIE WALK, individually and as parents and natural guardians of CHELSEY WALK, a minor Plaintiffs Civil Action - Law v, No. 2005-156 Civil Term MICHELE BLEVINS And FREDERICK D. RICE Defendants Jury Trial Demanded ORDER OF COURT AND NOW this day of ,2005, upon presentation of the Petition for Approval of Settlement and Distribution of Proceeds of a Minor's Claim and after due consideration of this Court, being satisfied with the propriety of the settlement and distribution, it is hereby Ordered and Decreed as follows: 1. As to Minor-Petitioner, Chelsey Walk, a settlement of $20,000.00 is fair, reasonable, and in the best interest of Chelsey Walk. 2. It is Ordered and Directed that the sum of $20,000.00 be distributed as follows: a. $ 13,842,97 to Petitioners as parents and natural guardians of Minor- Petitioner, Chelsey Walk, to be deposited in a federally insured banking institution for the sole and exclusive use and benefit of Minor-Petitioner. Proof of deposit shall be filed of record, No withdrawal of said funds may be made without prior leave of this Court. Upon Minor-Petitioner reaching age 18 (date of birth: April 22, 1992) said funds shall be turned over to Chelsey Walk. b. $ 771.50 to Petitioners as parents of Minor-Petitioner for out-of- pocket expenses as indicated on Exhibit F . c. $ 5,000.00 d. $ 385.53 to Martz & Gailey for attorney fees, to Martz & Gailey for reimbursement of advanced costs. 3, The funds received by Petitioners on behalf of Minor-Petitioner, Chelsey Walk, shall be deposited by Petitioners as guardians of the account on behalf of Minor- Petitioner. No withdrawal offunds shall be made during Minor-Petitioner's minority without prior leave of Court. Proof of deposit shall be filed of record with this Court. The account must be restrictively endorsed in accordance with the withdrawal restrictions set forth in this Order. A copy of this Order shall be provided to the depository banlc Counsel shall assist in the deposit. Upon Minor- Petitioner attaining the age of 18, the balance of the account shall be turned over to Chelsey Walk. 4, It is further Ordered and Directed that Petitioners may execute releases in favor of Respondent Blevins and Respondent Rice upon payment of the settlement figure. J. . . IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA DENNIS and DIXIE WALK, individually and as parents and natural guardians of CHELSEY WALK, a minor Plaintiffs Civil Action - Law VI. No. 2005-156 Civil Term MICHELE BLEVINS And FREDERICK D. RICE Defendants Jury Trial Demanded PETITION FOR APPROVAL OF SETTLEMENT AND DISTRIBUTION OF PROCEEDS OF A MINOR'S CLAIM Pursuant to Pennsylvania Rules of Civil Procedure No, 2039 Petitioners, Dennis and Dixie Walk, as natural parents and guardians of Minor-Petitioner, Chelsey Walk, by their attorney, Herman A. Gailey, III respectfully represents the following: 1. Petitioners, Dennis and Dixie Walk (hereinafter referred to as Petitioners), are adult individuals, husband and wife, residing at 120 Dudley Road, Six Mile Run, Bedford County, Pennsylvania 16679. 2. Petitioners are the parents and natural guardians ofChelsey Walk (hereinafter referred to as Minor-Petitioner), age 13, whose date of birth is April 22, 1992. 3. Respondent, Michele Blevins (hereinafter referred to as Respondent Blevins), is an adult individual currently residing at 709 Phoenix Avenue, Fruitland Park, Florida 34731. . . 4. Respondent, Frederick D. Rice (hereinafter referred to as Respondent Rice), is an adult individual currently residing at 801 Myerstown Road, Gardners, Adams County, Pennsylvania 17324, 5. The action was commenced against Respondents by a Complaint filed on January 10, 2005. 6. The litigation arises out ofan accident that occurred on June 19, 2003, Minor- Petitioner was a passenger in Respondent Blevins' vehicle when a motor vehicle accident occurred involving Respondent Blevins' vehicle and a vehicle being operated by Respondent Rice. A copy of the police accident report, setting forth additional factual information is attached hereto, marked as Exhibit A, and made a part hereofby reference. 7. As a result of the accident, Minor-Petitioner sustained a grade N liver laceration, rib fractures, and post-traumatic anxiety, 8, The injuries suffered by Minor-Petitioner required a six-day inpatient hospital stay (from June 19, 2003 through June 24, 2003) and follow-up care provided by Dr. Andreas Meier of Hershey Medical Center, and Minor-Petitioner's family doctor, Dr. David Kerstetter. Chiropractic care from July, 2003 through the beginning of 2004 was provided by Dr. J. Scott Mohr, Incorporated herein by reference and attached hereto as Exhibit B is a copy of Hershey Medical Center's discharge summary and copies of follow-up medical treatment records. 9, Minor-Petitioner has successfully recovered from her injuries, which were initially life- threatening, and has required no medical treatment since January 19, 2004. . 10. A narrative report dated November 29, 2004, authored by Dr. Andreas H. Meier, primary treating physician during Minor-Petitioner's Hershey Medical Center hospital admission, outlines the nature of Minor-Petitioner' s injuries, and is attached hereto as Exhibit C. 11. Petitioners are insured under an automobile liability policy issued by Erie Insurance Group, a copy of which is attached hereto as Exhibit D. 12. Said policy of insurance reflects a validly elected limited tort option, allowing recovery of non-economic damages only in instances involving "serious injury, serious scarring disfigurement, or death." Copies of the tort-election forms are attached hereto as Exhibit E, evidencing the valid election of the limited-tort option. 13. Respondents, through their insurance claims representatives, have raised the issue of the limited-tort threshold as a potential bar to recovery in this case, which risk was a factor taken into account by Petitioners in considering the settlement offers. 14. In the course of her recovery, Minor-Petitioner has incurred $18,561.07 in medical expenses, which has been paid by Erie Insurance, the first-party benefits provider, 15, No additional unpaid medical expenses remain. 16. Petitioners, Dennis and Dixie Walk, parents or Minor-Petitioner, have incurred out-of- pocket expenses amounting to $771.50 as is outlined in the Schedule of Out-of-Pocket Expenditures attached hereto as Exhibit F. 17. Petitioners contend that the injuries sustained by Minor-Petitioner were solely and directly caused by the negligence of the Respondents. . . $ 30.00 119,03 22.00 15.00 43.28 2.10 ,50 10.00 55.50 88.12 18. In an effort to amicably resolve the claim of Minor-Petitioner, Respondent Blevins, through her insurer, Progressive, has offered $2,000 towards settlement. A copy of the proposed Release is attached hereto and marked Exhibit G. 19, Respondent Rice, through his insurer, Westfield Group, has offered $18,000 towards settlement, for a total settlement proposal of $20,000. A copy of the Westfield Group's proposed Release is attached hereto and marked Exhibit H. 20, Petitioners, on behalf of Minor-Petitioner, have agreed to accept this offer in full and final settlement of Minor- Petitioner's claim against Respondents, subject to approval by Your Honorable Court.. 21. Petitioners have executed a contingent fee agreement with the law firm of Martz & Gailey providing for a twenty-five percent (25%) fee, plus costs advanced. 22, Martz & Gailey has advanced the following expenses: Hershey Medical Center Recordex Medical Copy Service Bedford County Pediatric Assoc. Dr. Mohr, Inc. ChartOne Medical Copy Service Sir Speedy Accurint Postage, phone, and facsimile Cumberland County Prothonotary Cumberland County Sheriff Total $ 385.53 23. Petitioners respectfully request that your Honorable Court approve distribution of proceeds as follows: A. $20,000,00 to be divided as follows: WHEREFORE, Petitioners pray your Honorable Court enter an Order authorizing settlement and distribution of the proceeds in accordance with the aforementioned terms and that Petitioners, as parents and natural guardians of Minor-Petitioner, may execute releases in favor of Respondent Blevins and Respondent Rice. 1. $ 13,842.97 2. $ 771.50 3. $ 5,000.00 4. $ 385,53 to Petitioners as parents and natural guardians of Minor- Petitioner, Chelsey Walk, to be deposited in a federally insured banking institution for the sole and exclusive use and benefit of Minor-Petitioner. Proof of deposit shall be filed of record. No withdrawal of said funds may be made without prior leave of this Court. Upon Minor-Petitioner reaching age 18 (date of birth: April 22, 1992) said funds shall be turned over to Chelsey Walk. to Petitioners as parents of Minor-Petitioner for out-of- pocket expenses as indicated on Exhibit F to Martz & Gailey for attorney fees. to Martz & Gailey for reimbursement of advanced costs. Respectfully submitted: MARTZ & GAILEY /1/--1; ~~ Herman A. Gailey, III, Esquire 96 South George Street Suite 430 York, PA 17401 (717) 852-8379 ID # 31097 f)l)LZX 6) cJJYz DIXIE WALK VERIFICATION I, DIXIE WALK, do hereby verify that the facts set forth in the foregoing Petition are true to the best of my knowledge, information and belief. I understand that false statements made herein are made subject to the penalties of the 18 Pa. C,S,A. 4904 relating to unsworn falsification to authorities, Date: 5;i y.,j0 S " VERIFICATION I, DENNIS WALK, do hereby verify that the facts set forth in the foregoing Petition are true to the best of my knowledge, information and belief. I understand that false statements made herein are made subject to the penalties ofthe 18 Pa. C.S.A, 4904 relating to unsworn falsification to authorities. ; j~~ lAJJk DENNIS WALK Date: 5) ,f\/ ,D5 DENNIS and DIXIE WALK, individually and as parents and natural guardians 0 f CHELSEY WALK, a minor Plaintiffs Civil Action ~ Law IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA v, No. 2005-156 Civil Term MICHELE BLEVINS And FREDERICK D. RICE Defendants Jury Trial Demanded CERTIFICATE OF SERVICE I hereby certifY that I have this date served a true and correct copy of the foregoing Petition for Approval of Settlement and Distribution of Proceeds of a Minor's Claim on the following individuals as set forth below by first class, United States pre-paid postage: Michael S, Ferguson, Esquire Nealon, Gover & Perry 2411 North Front Street Harrisburg, Pennsylvania 17110 Attorney for Respondent Blevins And James p, Erickson Westfield Group 201 East Oregon Road Lancaster, Pennsylvania 17604-3010 Insurer for Respondent Rice Date:~ -?H ,~ EP Herman A. Gailey, III, Esquire MARTZ & GAILEY, LLP 96 South George Street Suite 430 Yark, Permsylvania 17401 (717) 852-8379 ill Number: 31097 Respectfully submitted: . m >< :T 5' "" }> e,./brf A -- fZi Bgi~l 0 l? I 1~'3T I Investlgotlon Date (MM.DD-YYYV) I ~ -0J!]-[lliIillJ ~ Q.-FAAf'I\P\cH I ~ ~~3i st I br{IT~L~rriV;;1 0 ~ IMU"i'I~lty I Municipality Nlm. fay of W... I Z 0 Z. \' DlC.k~ 0 Sun a Thu " OMon Offl CrlKh Time (m;() No ot Units: .If,> 00 compl.to 0 Tue 0 S.t form f 0 Wed 0 uok Notify PENNDOTO Yas a No Malntenlncw 66/36/2663 14:68 7178457431 DALE E ANSTINE PC NA '{.)U::::VITIY~ ) COMMONWEALTH OF J JSYLVANI,A....., ./ poUcE CRASH REPORTllIIl:i FORM"',' Ubi 0 Ca:Se Closed Repombl. Crilln! . I ..fJlA~90 1. <29 Ye, 0 No ~ Ye' 0 No \ ,d- I'racinct II CA\2.W:.Lt. /7..l10 ~o1Or ii.~ i , i S Worlc:zon8 (If Ye~ Comp~Qre 0 Yes SchoollJus 0 YeS /'orm M s.i:t1Of1 29) Rolated 'n~nfllHlnn Tv~ ~ 4 Way lntQrsection 0 .V' Inte~ectlon 0 ~~:~~O" o MidbloCK 0 T Inte"QCtlon 0 Traffic Ci((laI 0 On R.mp Round About Tr.v.' Lanes: ~ Umn ~~ . ,g . Stroot Ending ~ 1~1l) I ~ I 3,e< ~ o OJf lUmp o Cm_ar ] . ;; ,a- u ,e .. ,509ft l'o:l"alll PAGE .,2 ,;1111111111 1111111111111 "I Crash Number P0501744 o North o South <S ~'St OWe" o Unknown ;~:iI:~ I ~IO I .. s.. OVarlil House: Nl.Imber (if applicable) ITIIIIJ For Mid"bto6; r;rUhQS only, US, portal HO~. Nl.Imbtr and mllke ,vn: Plindpal "-oadwllY Street Name i, filled in if uti" ~nis option o Railroe.d Cfosslno o Othor O CROo.udnty 0 Local Road 0 Privata or Str,at Ro~d o Otharl Unknown ;0 North ~ ~ 0 South LL-L..L..L-J St Ending ;:> 0 ~ast' ITJ 0 Or MIles , "' We" CIJ.D 10 North Oi5tanc~ F(Orn 'r,aSh . 0 South ><one to Landmo!!1 St Ending :'S 0 (For Cr~.h Ia~" OJ Eost L~ndmark 1 and" ! j 0 West Landmark 2) "' reg,;; I Minute> Secood, Longitude: -., [[II] :[[1]]. ~ o Turnpike CSi Stote Spur Hi nwa [~r r~id5T o In'CematQ a fumpike (Not Turn ike) (EastIWest) foi ~Uj;Fn Fr'I'oprIJI Strut Name ARL ] · f ~ ! Street Ending [E].b 1 ~ 0 Inter5t!t~ 0 Turnpike ~ (Not Tumplke) (Ea,tlWtst) o Turnpike Spur IE St,te 0 County Highway Road 1 i ~ ~.. . f ' ... ~ j : : rterFr Rj NUj illJ. 0 Or i Or 'nterseding Street N.m. 1 j Ple.aSli Enter tnformation for BOTH Landmarks If U,lng ThIs Option ~ Ilni~r Ri NUj EI:D. 0 i Or In_In Street Nome j T S t"7o j latitude: ,4 Minutes Sel;onds ~:[TI].I~I,-I (El North ~ CJ SOuth E 0 E"t .~ 0 West o 0 Unknown o local Rood or Street ~ o Private Roed o Otherl Unknown , , '.l T,..Hir r~"'''t'nl 04llvice o Yi~ld Sign a Pallca OfficQr or TCD hlnrlion/fttJ ~ o Not Applicable o Traffic Signal a Active: RR C rO~5ing r1egmM 0 No Control$ 0 Device Functioning 0 Emergency . o Oth.r Type TeD Improperly pre.l"lp\ive o Flashing Traffic Controls Signal ~ Stop Sign o Passive M o Unknown o Device Not ~ Device Functioning 0 $ign..1 Crossing Controls Fun~tio(jil'lg Propely Unknown f · A ! L:mD CJMMI (If ftNct AppJil2b1p., ~jp ~ of ~ un" Closure section) o Not Applicable 0 Piutially S) Fully a UnknO'Aln Ia/tJ5; Y., 0 No ~ OI>MUUOtJ Unknown 0 ~nff 1"1na',.... l1it<<1t1>4 ~ North o South fnj n",.,O tJDJl1d. '< 30 Min. ~ 30~60 Min. 0 1-3 hrs 0 3-6 hrs ,?RhC . ........00 (1 :1142) POLICE COpy o o hst 0 North and SOlJth 0 All Wijii ~ East lmd West (N,S,E,VV) o 6.9 hrs 0 > 9 hours 0 Unknown 66/3.,12.,63 """"'II' .r .r'.... 14:68 .... t.~....' 7178457431 DALE E ANSTIN~ PC PAGE .,3 --' " , ;.:;,..., COMMONWEALTH OF PENNSYLVANIA POUCE CRASH REPORTING FORM P.9-: I [gJ 11111I111I111111111 P0501744 Cra,h Number I M5002 I fl*a U5I 0nJy 0 ~ MellOr Vehicle in 0 l'ilt & Run VQhic;[Q 0 U\QgOlJly P:.rkQd 0 Legally P!rk.ed 0 Non - Motorized CommorcJ.a1 Vehicle :5 ;r,s: Ttansport o y" Cl:l No .. - 0 ~de5tri!n 0 Pctd~mian on Skates, 0 Disabled From 0 Tr~jn 0 Ph:ilntom VQhic:lQ ~ in Wheelchair, etc Previous Crash (If YQS, Ccmpltlttl Form C) (If .Pedestrian~ or -Pedestrian on Skates, in Wheelchair, e-tc., Com fete Form M, Section 28) Unit No @OJ MI Date of Birth (MM-DD- YYYV! ~ @IT] @IT] [JJ3I]TI] Tel~lIhone Number lill- ?'1~Hf71 \ I ~ I~ I Delete? CJ State crus ~IC Ii 'S " -I :. - ~ 'C g . 'tl :t > Drinr or Pfld.~tri.n PhVfJc.J Condit/on ~ Apparently 0 Illegal Drug 0 NormaJ " Use o Had8..n OS" 0 Drinking Ie... AlcohoVDfUQS SUsDecteQ ctJ No 0 lIIogal Drugs o Alcohol 0 Alcohol and orugs o o Medication Fatigue AslQ;p o Medication o Unknown Unknown Alcohol Tesr TvlJe ~ TQSt Not GivQn o Blood Prim.rv Veh;d~ Code Violation 11'30\ C~ (hllrged? ~ YiS 0 No o Other o Unkn~n if Test GWl!n O Un nown Result> o B""th o Urine CJ rest Refused O Test Given. Contaminated Results Driver Presence l=Driver Op~at!d Vehicle 2=No DrivQ( 3-0ri\ler Fled Scene I 4;:;Hit and Aun ---1- 9.Unlc.nown Alcohol Tast RflSula [Q]. IT] IT] OwnflrlDrlvor OO-=Not Applicable rom 01 :=Privllte Vl!!:hkle Ownedi' ~ LIiiISlid by Orivlir 02_prlv.te VQhido Not Ownl!dIleased by Drlvtr 03_Rented vehide O.4_State Pollee Vehide 05-PENNDOT Vehicle 06=Other State Gov Veh 07_Munlc:;lpal Pol~ Vlilh OS-Other Municipal G~rnme"t Vehide 09.F\1doral Gov VQh 98-0ther 99=Unk.nowr'l Same 4S Drlver~ . Address I City I SUtG I Zip I VIN t *Make Code I I sill (Slla overlay) I I I e v.hie" Mak. 11l--\Q,lOA Vehicle IVIQd~1 o e g 1 ITBJ:itl] I P\CCORD Reg, Stot. Est. Spood Vohid. Towed To",.d By ~ [EJQIJ re:l Ye, 0 No I MvtJ.2.t4'..s TOW'\,J(? Policy No Ilsit}\&\/O'H Model Yllar g 11 t :5 In~U1anCII Insuran,e CQmpany ~ Yes 0 No 0 ukn. I Cl"l",,, ......r,vE. !'lOwnl~l 7-Semi-Trlliler 8=Other 9-Unknown Tag No I Tag Year II Ta'st 10 fi1flf laTowing Pass. Veh D 2= Towing Truck 3_Towing utility Trailer 4_MobilelModul8r Home S=C.,mper 6_FulJ Trailer IlJf1ftJ!I. Unit No. of @] - Trailing .! Units: i ~ 'Mov.m.nr IQJI] .V.hld. Position [Q[!] Olro~f"'lOf I' I I Tr.v. 1"4. Vehjcl~ Color 06.Vlilllow 07=Silver 08oGold 09=Brown 1 O-Oran~~ l1-Purple 12_ot!'11i1f g9=unknown "'S.e Overlay 20-Unicycle, Bicycle. Trlcycll 21=Otner Pedalcycle 22=HOfse & Buggy 23=Hor~ & Rider 24..Tr:lin 2S-.Trolley S1a-otl'1er g9_Unk,nQWn ~ CD l-level 2-UPhlll SD<<I~J Usacut 10101 12.CommQrci~1 P.olS;SliInglilr C~rrier 13_TiSlti 21- Trtlctor Trailer 22..Twin Tr~iJlilr 23.TlilJlli TI<lil~1 31 =Modlfi,d VI" 9'3=Unknown Vt!hicJ" TVDe f(5TTl( 01oAutomobil. ~ O:Z-Motorcyde 03-8u5 04=Small Trvcll: (If .02", Complere Form M, Section 26) (If "ZO" Dr "21", Complete Form M. $<<tlon 27 OS-LarQ' Truck 06_Suv 07=Van , O=Snowmcbil, , 1=Farm EquilJ 12.(OIlstfu(.lion Equip t3-ATV 1s..0ther Type Spec Vel') 19=Unk. Typll SplK Vlilh D;,~tM /ndJe:ltor r=51 O-None 2-FunC1:ional ~ 1-Mlnor 3-Di~lIblin9 g.Unk.nown @N] aO_Not Applicable o 1_fife Veh 02_AmDulal'1c' 03...Policc 08::-:011Il~r Ell1t:I~~rILY Vehiel, 11=PlJpil Transport OT_Blue 02_Red 03...Whi1C Q4:;:;Green OS=Black, 3_00wnhill 4.=Scttom of Hill 5=Top of Hili 9=unknowl'1 R,D;IId AJiQnment rtl 1 ~Straight ~ 2-Curved 9..Unknown 'n/tf;,J Imaatt Po;nt rt12l OO-Non-Collision ~ 01-1~_c:lock. POlnu 13=Top 14aUndercarriage 1 5_ Towed unit 9S1=Unk,nown .,6/3.,/2663 14:68 ., /'\",.r . " ,..,WA () ]nlj~lH Of,..,dIlNSYLVANI!'. ...... PClf.8iI.~H,IlEPORTJNG FORM 'M 500,2 j l~""on~ 7178~57431 DALE E ANSTINE PC PAGE .,4 111I1I11mlllll~1111 P0501744 ;" I Cr..'h NumbQr POlga; I mJ J- I. .I .. ~ d Motor Vehide in ._. Transport: o P~dMtrian ~haf1tom Vehicle o ~ Non. Motorl;ed Comm.rci.1 VehkJ. o y" ~ No lIB, !mil (If y~s. Complere form 0 Dele",? o l,.,t Nlme JQto Form M, SoctJon 28) MI Dlto of Slrth{MM-DD.YYYY) [] [ill] rn::fl 0I1JI[gJ TelePhone ~~m~r 1/1l-~-e73b I I rp\bl31 (.Itt I I Unit No ~ State aass ~I<:. AlcohoVDnJaI $1I.r1J.~d Q!! No 0 IIl<g.1 Drug, o Alcohol 0 Alconol and Dru9~ Driver or PrHlestrlim Phvs/QI Condition ~ ~gf~~ntIY 0 ~:e'l Drug 0 o S~~k~:^ 0 Sid< 0 o Medic~tion o unk.nown F~tigue o o Medication A,leep unknown Alcohol Test Tvne ~ Test Not Gill"en o alood Prlmarv V_hid. Code VloI.non I 3322>Cb) Charged? Q'!f y" 0 No o Bt@ath o Urine OOthar O Unknown if Test GIY~n O Unknown R;sults Q] Orlvv Presence Altohol r.lt Results [Q]. CD o T~st Refused r-'l Test Gh/in, \.,......01 Cont;lminated Re1Ult5 1 sCriver Operated V.hide 2aNo Driver 3=Drivliilr FICild Scene I 4=HJt and Run -l- 9=Unknown Own.rlDr;ver OO=No\ Applicable 01::P!1vat~ Vehide OwnE!dl Le.~d by DriVQr 02=Private Vehicle Not Own~dA.ea!ed by Driver 03=Re:nted Venic!. 04..51ite pollce Vehicle OS"PENNDOT V.hida 06..Otner Stat. Gov Vth 07_Municipal Pollee Ve:n 08=Other Municipal Goverl"lment Vehidii 09=Federal Gov Ve:h 98=Other 99.Unknown ~ S.;am. as Driver 0; OWner- First Name c .2 J 11.2 S Ji ~ > V.hitle Mak. GA@.rJCJtS PA (l3.2,,lt IICl:\ev~7 Mod.' Yo:lr Vehld. Mad.1 !\1 IS \ S 2.. If 0 6 ~ 12-SCV Reg. State Est Sp.1td V.h;M Towed Tow.d ay ~ ClliD o Yes ~No I IlIsur.nc. In!l:urance Com~"y Policy No ~Y" ONo O~~~wnIW~-n1~ IIARJeS/Cfl'1 I.a/lI.!l9. M!!!! No,.of @] Tralhng Units: lQ;Towing Pe". Veh O 2-Towing Truck 3=Towing Utility Trailer 4=MobilelModular Home 5-(imper 6~Fuli Trailer 7~emi-Trai1er 8=Omer 9.Unlmown Tag NQ I r~g VOir 1/ ,agSt, Irll! lIntt ~on of ~ .Vohldo P..fllon [QIIJ .Mo""monl @ill 'See Ov.rl~ 20=Unic::yde. Bicycle, Tricycle 2' -otM~r ~"c:ycle ~2-Harse II Buggy 23.Horsa & RidQr Z4.Trai" 25=Trolley 9B.Other 99_Unlcnown SDe<i.,I V~QQ 10101 i VehlC/. Color o6..nilow 07 =Silver 08.Gold o9""erowfl 1 a"Orang. 1 'oafIurpla 12.0ther 99=Unknown 12:=Cortlmerci~1 Passengllr Carrier 13.Tax; 21 =Tractor Trailer 2Z.Twin Trail"r 23.Triph2 Tr:.lj~ 31 =ModJfied Vt:h 99~Unknown Vehicle Tvoe I of LJ.l 0 1-Automobil~ --. 02.MO[Orcyc.'~ 03~Bus 04-Sm1511 Truck (If "02", Compl.r. Form M, SlJCtIon 2:6) (If "20" Dr "21", CompJ~N Form M, Section 27) as.L:lr9Q TrUCk os=suv 07_Ven 1Qc;tSnawmooile 11 _Farm Equip 1 ~-Con:;tructlon Equip 13=ATV 18=Other Type Spec Veh 19::1Unk. Typ~ Spec Veh DltmlJtH 'ndlcator 101 n_Nr:'lr1t:> i..;;lln(Ti('Jnt!l1 1 =Minor 3~Di:sabling 9=unknown ~ CO_Not AppHcilbl", 01_Fire Veh 02aAmbulanCl! 03_Polici Oa_Otl1er Emergency Vlilhicl. '1 =Pl,jpil Transport 01-Blut 02-R.d 03_Whitl2 04~Gr~n 05t=:al~ck fnitl'.1 fml>>d Point r(5T7S1 OO.NQn-c;:ollisioll Cl...::.J 01-12,.C1o,k Point,; 13= Top ~ OJ ,=,.,,1 2=Uphill 3=Downl'1ill 4s6ottom ot Kill 5=Top of Hill 9=Unknown R~d A/ianml2nt OJ 1=Straignt 2=Curved g-Unknown 14.Undewmillge IS_Towed Unit 99::Unknown ..^_.....~."'" "...........' POI ,roE COPY . P~GE. .,5 DALE E ANSTINE PC 66/36/26.,3 14:68 7178457431 ~~ ~ ' ,,- '~~1!q{~:;~~O;:~~~~~~ArifA', '., AA 500 3 I "'"" 0.. On, 1111~1II11W1~""~H P0501744 ..., Cr.,h Number Page I BIJ A ~nn 1:vqe: 1=Driwr 2-PZl5senger 7-Pedestrian SoOther 9-UnkrlOwn S~,. Pn-n'Nfln: D OO-NOI A P"-,,,engerlOccupant o 1.Driver . All Vehicle:s 02>>ront Seat Middle Po:srtion 03==Front Seat Right Side 04-Second Row - le:ft Side Or Motorcycle PaS!~nger OS-second Row - MidtlJe Position 06.SllCond Row. Right Side 07=Third Row Or Grellter. left Side OS_Third Row Or Greater ~ Middle Position 09-11'1(rd Row Or Greeter- Right Side 1 O=Slee:per Section of Truckcab 1 1 =In Oth~r Enclosed Passenggr Or Cargo AtQ,] 12..ln Open Area (Bllck Of Pickup, Etc.) 13- Trailing Unit 14-Riding On Vehicle Exterior 15=Bus P~$SQnger 98=Other 99=Ur'lkriown E ~~~~/~~~t~~~PPllcable 01=5hovlder Salt U.ed OZ~lop Selt U.ed 03-Lap And Shoulder BaIt Used 04-Child Safety leot Usod OS-Motorcyde Helltlet Used 06.Bicycle Helmet Used 10:::lS.fity aelt Used Impropl!!rly 11...Chlld Sai,ty Se.!lt Used Improperly lZ-Helmtt USQd tmpropl!rly 90-Re:straint,Used, Type Unknown 99_Unk:nown G &~~~n~pplicabla 1 =Not Sjeeted Z.Totally ELooed 3-Panially Ejected 9,..Unknown H Ej~cti()fr Pltth O=Not Ejected / Not Applic",ble 1- Through Side Door Opening 2= Through SidQ Window 3e Through WlndshiQld 4-Through 8ack Door S_ Throll!;!h Back Door r"ilSHne Opening 6.::Through Root Opening (Sunroo1/ ConvQftible Top Down) 7=Throu9h Roof Opening (Convertible Top Up) 9=Unknown ,~ I Frtrinttinn' O-Not Applicable l-Net Extricated 2.Extricated By Mechanical MeClns 3=Fr."d By Non. Michal'1ical Means 8::::Qther g-Unknown m: B. F -Female M-MlIle U kl/nknown ,~ i i .. ! Safaty EmJ!pmNlr T~ F OO<oNooa u..d I Nor ppllcable 01 :.Froot Air Bag Depl6ye:d (For ThiS Seat) 02.Slde Air S.g Deployed (For Thi, Seatl 03-othor Type Air sag Deployed 04..Muftiple Air Bags eployed OS:::Motorcyde Eye Protection 06=Blcycltst WQiHil"l9 ElbowlKneiIP.ds 10=Air B.g Net Oltployod, Switch On 1 1 -Air Sao Not Oeployed. Switch Off 12-.A.ir Sag Not Deployed, Un~ Switch Se,"ng , 13-Air Biil9 R.emoved (prior To Crash) , 9-Unlcnown If Air B!g Deplo~d gg.Unknown ~iurv ')€'lf@r;nt: C -NOI Injured 1=Killed 2..Major Injury 3_Moderate Injury 4.Mif'lcr Injury B=lnjury, unk Severity 9=unknown if Injury EMS Agancy: I ~ ~~f.S eI"\S I Medical Foclllty: I~s~ ~1I("Tp.,1.. , Unit No ....on No I Da.. ." Birth (MM.DD- YYYY) A 8 C D E F G H I @ill ITD DeO'e7 [IJ- [I] - ITIIJ [][EJ@]@ill[Q]!J[gJJ [Q] [QJ[QJ Nam. f Address I PhDne ~ Some a. I Op.racor 4 I EMS Tr.lnlpon I8l Yo. 0 No Unit No Person No I 7 Date of Birth (MM.DD. VYYY) ABC D E F G H I @I!J ~ Dot. [QEJ -I z.1 2.1- [Jli]ili] [3J [f] [}J I 0 141 [QTI]@]QJ [QJ [Q]@] Name I Address I Phone o~~I:rlc.uL5tA 1'-1, WAUl C20 lUl.b~ 5\x;."'II1.e~ ~ 1{:b1'\ tA"t..q-Z,lo-9'ibl I I:MS Transport @Y.' ONO Unit No Perlion No D I 7 Dlt. ~Blrth (~O- YYYYJ A ..!!. C ..!;C. E ..t.. G H I @]J] ~ 0" @RJ-o:JI] -u:r:illnJ [1]lIJ [b] 10 I b IlQilll 0101 [QJ@][QJ N~me / Addres!l / Phone D~~~I::rICOR:! L. &e'i.hIS S_E. ,,~~~ A<, ol'f'~1\-1 . I EMS Transport ~ ~Ye' ONO Unit No P.....n No Delete? Dote of Birth (MM.OO.YYYY) ABC D E F G HI'; '~, [OITJ 0 ITJ-[o-ITIIJDDOo:JITJ[oOOEJ'i Nam. / Address I Phone EMS T ~:',',' I r.nspol't' 5~me as . o Op.r.tor I 0 YQS 0 NO , COrn D~te1 EIrtrrErroDDorndJrnoDDi':i; Nanw I Addr.ss I pf1on. EMS Transport D Sijlme as I I OpQr.:ator 0 Yes 0 No rnrn 0~t.7 CI:rtIfEI:rrJDDodJdJmDDD N.me I Address I Phone !MS Tranlport O Same III I I Operator 0 Yes 0 No FOAM'AA-OOO(121Q2) POI fr.s: ~npv 66/3"/2663 14:68 7178457431 ~~~EALTH C. .:NNSYlVANIA.- ~ POLlCE,CRASH REPORTING FORM AA 500 4 I-'u"o", DALE E ANSTINE PC PAGE "6 ~11111~liIl11lll1n P0501744 Crash Number I Pago 1[2] Cra3h DescrlDtlon [J] O-Non-Ccllillion 2!:tl:htad On 4=AngI. 8.S1d"Wlft9 8=Hit Pede8t/1an ,~ g , -Rear End . 3-~ar 10 Raar 5i~~TrocIiOn) (Oppos te DlrQctlon) ( acl<lng) 7:Hlt FlxQd Object 9=Otner/Unknown 1;{ Relation fa Roadwall [B] 1 =On Trave! L.anes 3-Medliim IS-Outside Trafficway 7-G01'e (Ramp Imer,ec:tionJ E 5 .e " 2-Shouldor 4.-f=l oadslde 6.ln Parking Lane g=Unknown , .Ii f illumination IT] l_Doyllght 3.0ar~ . Street S=Dawn 8=Olher -; ! 2=garK ~ No L1g Is o-O~~~~~iI " - tree! UgtltS 4=Oullk 'U Wuth1:lr CondItions [] '-~g~~y= 3-51." (HIlII) S-Fog 7.810.' & Fog g_Unknown ~ ! 2-R.ln 4aSnow 6.Rain & Fag B-Other "'" [Q] o-Oi)' 2.~,nd, Mud, Oirt, 4-Sluah 6-loe Patch~ Road Surface Conditions a.other 1~Wet 3.Snow Covered 5=108 7_W%", ;o~"nding or OVln ~arm !!vent L/R Most? Utility Pol. NumlMr !ila"ful Ewnu (Harm EventJ 30-Hit Fern:e Or Wall 1 [lliJ [BJ 0 ITIITITI 01=Hit Uni11 31::Hlt Building Unit No 02=Hit Unit 2 32:o:Hit Culvert [Q[]2131Q] [!J ITIITITI 03=Hlt UOIt 3 33=Hit Bridge PIer Or Abutment Ci9 04=Hit Unit 4 34:::;Hit Parapet End 05=Hit Unit 5 35=Hit BridPce Rail 06.Hit Othlilr Tr.fflc Unit 36-Hit BO\I i:ler Or Obstacle PIQ~~1l Put] rn D ITIITITI 07:.Hit OtliIr On RoadwilIY ~\tOfttsjf) 0 08:Hit Other Animal 37-Hit Impact Attenuator Sfl~ullntiaJ 09-ColrlSion With other Non 38_1..1it ~ire Hycltant rder rn 0 ITIITITI Foxed Object 39.Hit Roadway Equipment . 4 0 11-Strudr. By Unit 1 40=Hit Mail Box i 12=Struck By Unit 2. 41 =Hit Traffic: Island j 13=Strua E1y Unit 3 42=Hit Snow Bank HiI'", Eva," LIR Mast1 UtUIty Polo Numbor ' 4=St"'," By UOIt 4 43-Hit Temporary Construction ,Ii [I] 0 ITIITITI '5-Struck By Unit 5 B.ilrrilH 1: 1 0 16-St1'lJCk By Other Tr.ffic; Unit 4a=Hit Other Fixed O~ect . Unit No 21.Hit Tr.. Or Shrubbery 49.Hit Unk.nown FllI.e Object .:: OJ2[TI ITIITITI 22=Hlt Embankml!!nt SO.Overtufn/Roll O....er - D 0 23=Hit util~ Pol. 51-StruCk By Thrown Or Falling .;. 24_Hit Tta K Sian Obj,ct ~ 2S.Hlt GuaId Rail S2=Pot Holes Or Othli!r Pfesse Put 3 [I] D ITIITITI 26=Hlt Guard Rail End ~ivliilmliilnt Irrli!gularities 0 27.Hlt Curb 53~acl<nif4!: Evtnrs in 28=Hlt Concretl!! Or S4=Fi~ In Vehicle S8'lj8ntlaJ rdor CD 0 ITIITITI Lol'lgitudil\ill BiillTiir sa-other Non-Collision 4 0 29=Hit hch gg.Uni::l'lo......." Hilrmful Event ~f~ Unit No H51ml Evtmt Most Unit No Harm -=.,.nt Oriver Artion (0) 1 )=Careless Or lUigil @liJ 1z.141 H:.rmful G2TIJ 13101 OO=No Contributing Action Backing On Roadw.y ~ 01_Dtivir Wa5 Disuactliild 18=Oriving On The Wrong th. criih o2_0riving lJsing Hind Held Phone Sid. Of Road DO not ,... lhill",fotmltlon 01'0 multiDl~ Dq~ 03.0riving Using Hand5 M'ee Phone , g.Making Improper Eltv;ronml!ntaJ I RaAdwav [Q]Q] 2[1] 30] 04=Making lI~i U'Tum Entrance To Highway 1 OS_JmproJ)QrJ rolos:s Turning 20=Miking Impropir EXIt PotlJnt/~1 F~ctorf (EIR) 06=Tumir\g_From Wrong Lanliil From HlghwilIY OO-NOM 11-Slippery Road Conditions (Ice/Snow) 07-PrOCHdlng W/O 21.careless Parkmg/Unparking CIIil.ilranCQ Aftor Stop 22=OvorIUnd.r -1' 01.Windy Conditions 12=Submnce On Roadway OS=Running S:d Sir Compensation At CUN!, I ~ 02=Suddll!!n We!tnll!!r Conditions 13=Potholes 03&()ther Wellther Conditions 14z.Broken O~ Cracked Pavement 09:QRunnin~ R Ug t 23=5peedin~ 1O.F.;ilurQ 0 ~ond To Z4=Driving tlO Fsst FOf ConditlOr'l5 04aOeer In RolldwlIY 1S.TCO Obstructed Other Traffic antrol Device OS_Obstacle On Roddway 16li111soft Shoulder Or Sl'1ouider Drop Off 11_ Ta~atin~ 2S.Follure io Maintain F'toper Speed " 06=Othliilr Animal In Roadway 2S-0ther Roadway Factor 1 Mu dtn 10000f1IOPfl~ 26.D~Ive1 Fleeing Pollc@ (Pol Chase) t ; " 07=Glare 29=Other Environmtrltal Factor 13.11I~.:l11y StoPP'Q On 0 27_DnvQf Inexperienced \:;;i, a OE=Work. Zon, Rel~t,d 99=Unknown 14.CareteS$ Pll$!ing Or L.ene 2S-failure To Use 5pecializtd EqIJip <~. g2=Afftcted By Physiall Condition " . '," FwsJblfl v.hid. F.llurvs (v;I 12=Wipers Change 98=Other Improp~ Driving Actions " . 1S=Passlng In No paSSln~ Zone i OO-None 06-E.llhllus1 13-o,ivtl' Se~tin9lControl 16.0riving The Wrong ay On 99..UnknoWf'l ~ 01.TltlJ$ 01.HQ.ildli~hts 14-BO~, Ooors, HOOd, Etc 1.W~Street .Ii 02=BraKQ Synom OBl:S~al ights 1S.TraiQr Hitch ~1t[Q]J] 10101 OJ 3 [I] 4 []JJ ,r 03=Steering S)'3tem Og.Ot er Lighu 16=Wl'lell!!ls , 2 04.Suspension 'O.J.lom 17=Airba;s i 05=PO\Ner Train 11=Mlrrors 18= Treller Overloaded ',',,,," ~~It [QE] [Q]Q] 2 IT] 19-Un5ecu~Shjfted ~~It I 0 l1J 10171 IT] 3m .m ~ 1. Trailor Load 1. 2 ZOolmproper TOvvi~ 21 _Obstructed Win shield ,.dMtri.n Act;on (I') 03=Wcrking ~~It 10 12.1 [9]Q] 2 OJ 99-Unknown , aO.None 04-'1Fusl'1ing Vehicle 01=Enttring Or Crossing At OS_Approaching Or Le.ving Vehic:le SpeCIfied location 06=Working On V_nidI lndlc~t.d Prim. FlctOr Unit No F:illttor codili 02_Walkil1g, Running, Jogging, 07.Standing 00 r\Ot rtptit'~ ifI'Ol'lMtlol'l on 101'2...1 lQG] Or Playtng 9S_0th1U mu~lll'l4: p,,-. 99=UMknown fiR V 0 P UnIt No [Q]I] [QJQ] UOltNoIOI2.1 10101 0 0 ;g) 0 If Elf' f$ mil Primll F.ctor Type, 1..V4J Unir No: bl.nk " 17 ,. " ,"Oft.., AA-500 {121tl2) POLICE COpy DALE E ANSTINE PC PAGE 67 ~llllllmlllllllllm P0501744 ..,,: -, er.sh Number "M 500 5 I Polic:. lJD Only ; Pi.ge I~ ,;+-,;,:~,7,~' i ' , ..,...-.,.....,. .~;. ~......, ;' '-: \~~/i l~ I ! .!.........i i i 1 ........+....- ..i .........t,....... ..~....-..._.+.. .....+... .--. '..L""'~".i""""j""""L,,~' i,i~~Q~,! ! : To! 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".,"!...,. .. .j...........I........ ~.... .....j........ ..;..... . .,.. .........,.......... ..., .......1.. ; i~0t ~",,\W;-m' " , ~"..j:,_::,J~~,-ifi:~t~...:i--':::::'!:'::'::., :':','::r, Witn.., Name Addre.. ........1 Phone " 1 NCWt. 2 ,..,}oJe Rl:t...o Narrative and additlon.al wltness.s: Acddent Investigation Notification ".u.d? ~ ~rty Damogo i!!) . I'WO (l.EV'\"IU) ~ ;'.. ~OfllM. ,u'1I00 112102:) -' POLICE COPY 7178457431 PAGE 68 DI\l..E E ANSTINE PC 'JllllIl1lllilllUlllllL____, __~_ ,. STATION ~RUSU ~ INV!STIGA'I1NO OfFlC~ -rPi . 5, DA'WI1Mi Of INe/CENT 2- V cJ( T [(./-4.5 06.!1 c./O~ 1106 6, LOCA'I10N S~03k AI P\Ne6~ RoAD DLCkrM0,J -rwf', OJM~P1..t\~ D <JJ. 7, ~ERSON(S)lNllOLVED ')P~~: '; l"\lu.\~c. &...elJltJS J3:J Lrt;rA.J~ 6AR.0\.lt~PA.M\Nuf\\,J.:lUf<,'1' 1M.s "1 '. C)~~L5e:.A "'1 At.,'ol.. J Il "(c-A.,liF' ~\l(.""\\.t.lv..J PA, MA"juft ,1\I.iJf:,'-( 'o\~~v..\ <; c..o~1. SU\lIr-l,L 10 WAJ <:>/=,&~~u.> PA. /'I\oll~~ ~OP>t rJ ~\l-\ ~ l4..QQ ~...;O'" ~~,.I MA~ PA......"'~t ~~2-: F~~I <.Ie. R\~I SB '(OA,<:lF' (i)ANlNU.s PA. ,JOilJ-'jV~ J nv,<..: f'lq'Z- Cl-\CVRO..!i WJ AC./c-uP. C SeA\i EL.--TS "'CICSNT DETAILS ,,-,\+1 wfJr5:. Nl1~-n\Sov,Jf) -t:>..J Sf:.()o?'i, ~l\.G. u..j~ "",^!::> $7i:JfP8Jf>t'i A. COP S\~~ 0...1 (>t~t. G~ p.;,~. cJ Peff'2..F\-r1&NJTt.c TO C-P.t5.5 ~tlt SRoo3,+. oPfR. ~I ] It.~ "!ll '""\~ V.v\"'t'l-2." F\JP ~+l I-Irt A, S"l11PS/0fJ AoI'D A 5-1b-JEw~i.t. A,u..,.~t Cv~ o/=, v-J.rr"tl welle TAICU 1:0 c"'~us\.~ ~P\"'AC.. ~ CI ". .n .'M own An Internationally Accredited L.w Enforcement Allencv C;lb/f 8 ~ m >< :T 5' "" OJ .Surg D/C Summary WALl\., CHELSEY N - 775916 * Final Report * DISCHARGE SUMMARY PATIENT NAME: WALK, CHELSEY N PATIENT NUMBER: 0365897 DATE ADMITTED: 06/19/2003 LOCATION: 7240 DATE DISCHARGED: 06/24/2003 SEX: F DATE OF BIRTH: 04/22/1992 RESIDENT PHYSICIAN: Aleksander L. Shifrin, M.D. PRIMARY CARE PHYSICIAN: None listed. ADMISSION DIAGNOSIS: MVC. DISCHARGE DIAGNOSIS: Grade 4 liver laceration. OPERATIONS OR PROCEDURES: None. BRIEF ADMITTING HISTORY/HOSPITAL COURSE: Chelsey is an l1-year-old female involved in MVC on June 19, 2003. She was brought to the Hershey Medical Center Emergency Room as a level II trauma. Her workup revealed a grade 4 liver laceration. She was admitted for observation and serial medical checks. Her hematocrit was stable for this admission. She required no blood transfusion. Her post-trauma course was, generally speaking, uncomplicated; however, on post-trauma day #4, the patient was still not productive of stool. She is complaining of abdominal discomfort consistent with constipation. She was started on intensive bowel regimen, which resulted in several bowel movements. Her abdominal pain was resolved. Social services, physical therapy, and occupational therapy were involved in the patient's care during this hospitalization; they specifically addressed her ambulatory needs, as well as her return to ambulation needs, as well as the anxiety surrounding the motor vehicle collision. The patient is currently afebrile. Vital signs are stable. She is taking the p.o. diet. The pain is well controlled. DISCHARGE MEDICATIONS: 1. Tylenol No.3 of 10 cc every six hours as needed for pain. 2. She was started on iron sulfate 220/5 mL p.o. g.d. 3. Laxative and bowel regimen of choice. DISCHARGE ORDERS/INSTRUCTIONS: Following discharge instructions were reviewed with the patient and her family prior to discharge, 1. She is to maintain a regular diet. 2. Activity: Two weeks bedrest followed by two months of no contact sports and only light duty activity. 3. She and her family were instructed to call 717-531-8521 for any of the following signs or symptoms: Acute increase of pain, temperature greater than 101.5 degrees Fahrenheit. feeding Printed by: Printed on: Shiner, Crystal L 8/21/20031 :59 PM Page 1 of 2 (Continued) Printed by: Printed on: Shiner, Crystal L 8/21/20031:59 PM Page 2 01 2 (End 01 Report) .Surg D/C Summary WALl<., CHELSEY N - 775916 intolerance, vomiting lasting greater than four hours, or other health care concern. FOLLOW-UP APPOINTMENTS: I. Follow-up appointment was scheduled with Dr. Ramer to evaluate the patient and further manage her post-traumatic stress surrounding the motor vehicle collision. 2. She will follow up in the pediatric surgery clinic in July 16, 2003, at 3:00 p.m., in the pediatric surgery clinic. It has been a pleasure working with Chelsey and her family. We look forward to seeing her back in clinic and hope she does well in the interim. U25244 DICTATING MD: Jason T. Bundy, MD ATTENDING MD: Robert E. Cilley, MD JTB/dts D: 06/25/2003 T: 06/26/2003 22:29 c: WP Clerk PEDIATRIC SURGEONS OF CENTRAL PENNSYLVANIA ~ Robert E. Cilley, M.D. III,,' ~' , Peter W. Dillon, M.D. " Kerry M. Fagelman, M.D. ~ rr Andreas H. Meier, M.D. '" CoJHD P. Gre~her. M.S.. R.D.. C.N.s.D. Numtionist ~I/ ~ Janet H. Shields, M.S.N., C.R.N.P., C5 r:linical Nu.rse Specialist :.._. ib;uddlo, M.S.N.. R.N. Pediatric Trauma Nurse Coordinator Beverly Shirk, R.N. Pediatric Trnuma Ca~e Manal!;et Administrative StatT: Marcia A. Krick Lee A. Naylor Tina Babbs Penn SCale Children'. Hospital P.O. Box 850MC HI!3 Hcnhey,PA 17033 Phone: 717-531.8342 Fax: 717-531-4185 Camp HilI/Harrisburg 101 Erfotd Road. Suile \01 Camp Hill, PA 17011 Phone: 717.920~5200 Fax: 717-76]-]320 York 2295 Susquehanna Trail, Suite A York, PA 17404 Phone: 717-846~lnO Fax: 717_812_9848 Division of Pediatric Surgery Department of Surgery Penn State College of Medicine Milton S. Hershey Medical Center Il.nnltat.pedlalricSUrt;ery .com PENN STATE .. PEDIATRIC SURGERY NOTE - July 9, 2003 PATIENT: MSHMC# 775916 WALK, Chelsey We saw Chelsey Walk in our clinic today in follow up for her recent trauma. She was hospitalized for almost a week for a grade N liver laceration. Initially, she had elevated LFTs and INR which normalized by the end of her visit. Her discharge hematocrit was 25. She was scheduled to return to clinic next week but she returned one week early due to some perineal bloody spotting which was noted. It was unclear whether this was coming from the rectwn or from the vagina. She has had no problem; with diet and bowel movements, She denies significant pain. She has, however, had a history of constipation which she treats with primrose oil. She still feels somewhat fatigued. Of note, her mom ,started her menses at 13 and one of her aunts at age 11. On physical exam Chelsey appeaTs slightly pale but otherwise in good spirits. Her weight is 30.8 kg. Her abdominal exam is unremarkable without any significant tenderness. She had a rectal exam which revealed normal tone with stool in the vault, no significant hemorrhoids. There was some blood noted on the maxipad but none on the rectal exam Impression: Chelsey has a history of trauma, but I still think that the bleeding is most likely early spotting from starting menses. It is not lUlusual to have menses start after a major traumatic event due to some significant changes in the endocrine homeostasis. As she is fairly fatigued and also somewhat pale, we will check a hematocrit on her, According to mom, she is already on iron supplementation. We would like to see her again in our clinic in about two weeks if the bleeding continues. Otherwise, if she is doing well, it would be OK for her not to Teturn to our clinic as she has a two-hour drive. Mom has our phone nwnber and can Teach us at any time. DICT. f1D BY ~~tr0k Andreas H. Meier, M,D, AHM/asap Specializing in the Surgical Care of Infants. Children and Adolescents An Equal Opponumty UmvCTsity .PEDIATRIC SURGEONS OF CENTRAL PENNSYLVANIA ~ Rebut E. Cilley, M.D. ~ Peter W. Dillon, M.D. " Kerry M. Fagelman, M.D. ~ Andreas H. Meier, M.D. ~ C.;j;en P.- Greeeher, M.S.. R.D., C.N.S.D. Nutritionist ~ .Janet H. Shields, M.s.N.. C.R.N.P., e.S. Clinical Nurse Specialist . Rzucldlo, M.S.N.. R.N. T :":':1Iric Tl"lIwna Nurse CoordinalOr Benrly Shirk., R.N. f"cdiatric Trauma Case Manager Administrative Staff: Mud.. A. Krick Lee A. Naylor Tina Babbs Penn Stale Children's Hospital P.O. BOll 850 Me HID Hershey, PA 17033 Pllone: 7]7-531-8342 Falt: 717-531-4]85 Camp HIlUHarrisburg ]0] Ertord Road, Suite 101 CampHil1.PAl7011 Phone: 717.020-5200 Fa)(:717-i61-1320 York :295 Susquehanna Trail, Suite A York. PA 17404 ?l1one: 717-846-1980 Fax: :'17-812-9848 DivISion ofPediatT'ic Surgery l)epartmelll of Surgery PenD State College of Medicine Milton S. Hershey Medical Center llenns tlltepedlatricl urgery .com PENNSTATE ~ ., ''-. David Kerstetter, M.D, 185 Hospital Drive, Suite I Everett, PA 15537 August 6, 2003 RE: WALK, Chelsey MSHMC# 775916 Dear Dr. Kerstetter: We saw Chelsey in follow up for her stage IV liver laceration after trauma. We had seen her recently for perineal spotting which we thought at that time was most likely beginning periods. Mom states that Chelsey is overall doing well. She has a good appetite, Her vaginal spotting has markedly improved and is only slightly present at this time. Her abdominal exam was completely unremarkable. Impression: Chelsey is overall doing welL She still has mild vaginal spotting which seems to be resolving. Her abdominal exam is negative and I think it is OK for her to resume sporting activities. I would still stay away from contact sports, Regarding the vaginal spotting, I would not pursue this any further at this point. I think it is very well possible that this is starting periods. If it continues to be an issue over the next few weeks, it may not be unreasonable to consider an ultrasound. Once again, thank you for allowing us to participate in Chelsey's care, Further follow up with us is only necessary on a pm basis. S"Jl) Andreas H. Meier, M.D. AHM/asap Specializing in the SurJtical Care or Inrants. Children and Adolescents .\11 El{uai l )pPUrlUI1lIV Ulll\'l'f~\l\ CJhJbJ!C- / m >< :T 5' "" () REer 'ED DEt - 2 2lJO~ PENN STATE !!5l Milton S. Hershey Medical Center .. College of Medicine Depcrtment of Surgery DMskm of PetlilllTic SU'Ke1')' Robert E. Cilley, M.D. Division Chief Peter W. DllloD, M.D., M.s. Vice-Chair, Dept of Surgery Kerry M. Fagelmaa, M.D. Community Practice Andreas H. Meier, M.D. Surgical Education and Simulation Mala R. Chinay, Ph.D. LUllg Development Research Program Coleen P. Greecber, M.S., R.D., C.N.S.D., NeonatallPediatric Nutritionist Janet H. Shield., M.S.N., C.R.N.P., e.S., Clinical Nurse Specialist SUlan Rzucidlo, M.S.N., R.N. pedianic Trauma Nurse Coordinator Beverly Shirk, R.N. Pediatric Trauma Case Manager Atlministl'lltiveStlljJ: Marcia A. Krick LeI! A. Naylor Tina Babbl lAClltions: Penn St.te CbiJdren', HOlpJtal SOO University Drive Me HI 13 Her.>hey, PA 17033 Phone: 717-531-8342 Fa,,; 717.531-4185 Camp Hill/Harrisburg 101 Erford Road, Suite 101 CampHiIl,PA17011 Phone: 717-920-5200 Fax.: 7t7-761~1320 York 2295 Susquehanna Trail, Suite A York, PA 17404 Phone: 717-846-1980 F:.x.717-S1:-n-:.r: CommUted to: Patient Care: Specializing in the Surgical Care of Infants, Children and Adolescents Research: LWlg Development Research Program, Biliary Atresia, Pediabic Surgery Outcomes, Advanced Technologies in Surgery Edu.cation: Medical Students, Graduate Students, Residents, and Patients Service: Pediatric Injury Prevention Visit JiS ttt: pennstllltepediatriuurgery,com November 29, 2004 Herman A. Gailey, III, Esquire Martz & Gailey 96 South George St. Suite 430 York, PA 17401 Dear Mr. Gailey: This letter refers to a patient of mine by the name of Chelsey Walk. I provided inpatient hospital care for Miss Walk between June 19,2003 and June 23,2003 after she had been injured in an accident and suffered a grade IV liver laceration. A grade IV liver laceration is the second most severe laceration of the liver. This represented a severe and potentially life threatening injury. The main risk of this injury is that due to the blood supply of the liver, significant and potentially uncontrolled liver bleeding may occur. Even though this is a rare occurrence, any patient with this injury could potentially suffer this, The current treatment protocol for this problem is admission to an intensive care unit with close observation, application of monitoring devices and frequent blood checks to see whether there is ongoing bleeding, As surgical repair of the liver is very risky and most patients with this injury do not suffer uncontrollable bleeding, we try to avoid surgical intervention and hope that the liver will be able to heal itself. However, there is always the possibility that bleeding may continue which would require surgical intervention and fairly significant likelihood of blood tran:.;fusi0US. As stat~d aGove, surgical reru.ir is a high-risk procedure. P:lt~en~$ that are successfully treated without surgical intervention, still require extensive time of bed rest post hospital stay and have a three to four month period of restricted activities. This is done to minimize the risk of a secondary injury to th." healing liver that could result in significant bleeding again. To the best of our knowledge after this period of time, the liver should be healed completely enough to allow the patient to go back to their regular activities, Another complication that can occur with these liver injuries is that there may be leakage from the biliary tree. This could result in intraabdominal fluid collections that potentially also would require surgical intervention, Sometimes if the injury is severe enough this may even require resection ofa portion of the liver. Another late complication of any liver injury is a so-called post traumatic cyst of the liver. An Equal Opportunity University Sinc eier, M.D. Page 2 November 29,2004 Even though most of these are asymptomatic, some of them can result in internal bleeding as well and cause abdominal pain. If these complications occur, surgical intervention may be necessary . I have received authorization for release of protected health information by Chelsey's father and therefore provide you with this patient related information. I would be happy to answer any further questions, Please contact our office if that is necessary. AHM/lan --- rn ~ 0' "" o &;h1bJ D DECLARATIONS BlGAPA I ERIE \i;' INSURANCE ~ ~~~J~S PI ERIf=' t'ne, PA 16530 , .........$} AMENDED DECLARATIONS 02 * * ATTACH THIS TO YOUR POLICY, ERI E L..:.URANCE EXCHANGE PIONEER FAMILY AUTO POLICY EFFECTIVE 06/03/03 SEE *** ON FIRST DECLARATIONS PAGE ITEM 2. POLICY PERIOD POLICY NUMBER 08/28/02 TO 08/28/03 Q08 2804984 H ITEM 3. OTHER INTEREST REASON FOR AMENDMENT - AGENT AA7638 GREGORY A GARRITY ITEM 1. NAMED INSURED AND ADDRESS 1,.,!I,II",II,.I".II.I..I,I""It,It,,,II.,,,.I.III1111.,,11 DENNIS J WALK & DIXIE L WALK 120 DUDLEY RD SIX MILE RUN PA 16679-9300 AGENT - GREGORY A GARRITY AGENT PHONE - (717) 243-3467 ITEM 4. AUTOS COVERED AUTO YR MAKE 1 90 PONT 6000 3 95 BUIC PARK ITEM 5. INSURANCE COVERAGE. 2621 SPRING ROAD CARLISLE PA 17013 8712 VIN ST TER SYM RATING CLASS LE IG2AF84T2L622~536 PA 2J A4L-M MM40 AVE 1G4CW52K5SH63f484 PA 2J 8 A4S-M FM40 I~ot~~Xb~~~ ~~~f~SAA~~E~&~tlALO~R~~Y&MSI~R~H~~NFb2~0~~~ #l #3 DDP *****GOOD ALL PRIVATE 81 83 DRIVER RATES APPLY***** PASSENGER VEHICLES. --- 68 68 75 8 2 2 7 14 108 141 4 12 509 --- THE LIMITED TORT OPTION APPLIES TO LIABILITY PROTECTION- BODILY INJURY S50MjPERSON $100M/ACC PROPERTY DAMAGE S50M/ACC FIRST PARTY BENEFITS- MEDICAL EXPENSE $100M INCOME LOSS SlM/MONTH, $5M MAXIMUM ACCIDENTAL DEATH S5M FUNERAL BENEFIT S2.5M UNINSURED MOTORISTS COVERAGE- BOD INJ S15M/PERSON $30M/ACC-UNSTACKED UNDERINSURED MOTORISTS COVERAGE- BOD INJ S15M/PERSON S30M/ACC-UNSTACKED PHYSICAL DAMAGE COVERAGES- COMPREHENSIVE - $50 DED COLLISION - S500 DED OPTIONAL COVERAGES- ROAD SERVICE TRANSP EXPENSES - COLL $20!DAY, $900/LOSS TOTAL ANNUAL PREMIUM FOR EACH AUTO 281 TOTAL ANNUAL POLICY PREMIUM $ 790 PREMIUM REDUCTION DUE TO THIS CHANGE $ 28CR ITEM 6. APPLICABLE POLICY~ ENDORSEMENTS~ EXCEPTIONS TO DECLARATIONS ALL AUTOS - FAP 04/97, UF,106 05/01. AF~N01 10/98, AFPA03 10/98. AUTO 1 - AFPUOl 04/99. AUTO 3 - AFPUOl 04/99. 84 8 2 2 7 14 ITEMS ***DRIVER INFORMATION AMENDED ***AUTO 2 DELETED ***RATING CLASS REVISED ANTI-THEFT DISCOUNT APPLIES-PASSIVE DISAa AUTO 3 PASSIVE RESTRAINT DISCOUNT APPLIES - AUTOMATIC BELTS AUTO 1 PASSIVE RESTRAINT DISCOUNT APPLIES - DUA~ AIRBAGS AUTO 3 ANTI-LOCK BRAKE DISCOUNT APPLIED AUTO 3 **********************************~**t************************************** * YOU HAVE BEEN INSURED WITH THE ERIE FOR AT LEAST 15 YEARS. THIS POLICY * * WILL NOT RECEIVE A DEFENSIVE DRIVER PLAN SURCHARGE FOR FUTURE ACCIDENTS. * *************************************~************************************** 6.x'n\bik m !;- C' ;::;: m - ,.-- ENE.... IHSUAANCE ERIE GP.OUP ;;;~i(i . P.O. 'Dll lln, IIUE. ... 1l'il30 Named Insured(s): f:,....)~ VAP:-A OJ NOTICE TO NAMED INSUREDS DENNIS J WALK " DIXIE L WALK 808 SEVENTH ST APT 1 SAXTON PA 16678-1012 POLICY NO. Q08 2804984 Agent: AA7638 PH. (717)243-3467 GREGORY A. GARRITY 2621 SPRING ROAD CARLISLE, PA 17013-8756 A. "Limited Tort" Option - The laws of the Commonwealth of Pennsylvania give you the right to choose a form of insurance that limits your right and the right of members of your household to seek financial compensation for injuries caused by other drivers. under this form of insurance, you and other household members covered under this policy may seek recovery for all medical and other out-of-pocket expenses, but not for pain and suffering or other nonmonetary damages unless the injuries suffered fall within the definition of "serious injury" as set forth in the policy, or unless one of several other exceptions noted in the policy applies. (See the enclosed Explanation for a description of "serious injury".) The annual premium for basic coverage is which reflects the coverages and amounts of coverage you have now. The annual premium for basic coverage as required by law under this "limited tort" option is . Additional coverages under this option are available at addi tional cost. B. If you wish to choose the "limited tort" option described in paragraph A, you must sign this notice where indicated below and return it. If you do not sign and return this notice,' you will be considered to have chosen the "full tort" coverage as described in paragraph C and you will be charged the "full tort" premium. I wish to choose the "limited tort" option described in paragraph A: Signature Line I. ~D:iY::iit) (U,JL D;&ly I~ ('{to C. "Full Tort" Option - The laws of the Commonwealth of Pennsylvania also give you the right to choose a form of insurance under which you maintain an unrestricted right for you and the members of your household to seek financial compensation fot injuries caused by other orivers. Under this form of insurance, you and other household members covered under this policy may seek recovery for all medical and other out-of-pocket expenses and may also seek financial compensation for pain and suffering and other nonmonetary damages as a result of injuries caused by other drivers. The annual premium for basic coverage is which reflects the coverages and amounts of coverage you have now. The annual premium for basic coverage as required by law under this "full tort" option is . Additional coverages under this option are available at additional cost. D. If you wish to choose the "full tort" option described in paragraph C, you may sign this notice where indicated below and return it. However, if you do not sign and return this notice, you will be considered to have chosen the -full tort" coverage as described in paragraph C and you will be charged the -full tort" premium. Signature Line II. Named Insured Date insurance agent, broker or company to discuss the UF-8385 lEd. 7190) . 00 REJECTION OF UNINSURED MOTORIST PROTECTION By IignlDg this waiver I am "jetting W1lnsured motorist coverAl" under this policy, for myself and aU relatives nsldlDg in my bousehold, VDlnsured coverAl" protects me and relltives living in my bousehold for losses and damAl"s suffered if injury Is caused by the DegJiseDCe of a driver who does Zlot hsve any inlurance to pay for losses aIld damages. I !mowingly aIld voluntarily reject this coverage. Date x Signat"'" of FIRST NAMED INSURED Q Policy Number Print Name of First Named Insured STOPI IF YOU HAVE REJECTED COVERAGE, DO NOT SIGN BELOW REDUCED LIMITS OF UNINSURED MOTORIST PROTECTION By aignin, this wliver, I am rejectin& W1ln1lUl'Od motonst coversge limits equal to my bodily mjury lisbility limits. I !mowingly aIld voluntarily ...Iect W1lnsured motorist coverage limits lower than my bodlIy injury Iiabilitylimlts aIl/ect the limit. chec:ked below, 1 15,000 per pereo.... 80,000 per accident 1 20.000 per perlOW' 60,000 per accident . 60,000 per pereo....loo,ooo per accideot 1100,000 per pereo....8oo,ooo per accldeot 1260,000 per pereow'Soo.OOO per accideot 1800.000 per accident (Combined Singte IJmlt~ 7ul~ ,,~ l'{qO x Q f'l ~ ).t(ll.{<f 1/-1 fl Policy Number Sicn roo NOT SIGN F COVERAGE IS REJECTED ABOVE,) \::)e." ,V\ \ ~ ]'. W1\ \ l _ Print Name of Fir.t Named IZlsured UNINSURED COVERAGE LIMITS By IignlDg this waiver, I am rejectloi stacked limits of IlJ>IIlSW'ed motorist coverage \IJlder the policy for mYlelf cd ....mbers of my bouoebold under which the limits of coverage avaDable would be the """ of limits for .acb Gl<ltor v.hlcle Insured under the policy. IZl.t6ad the Umlts of cover.... that r am purchaaiog .hall be reducod to tho limits .tated m the policy. I !mowio,ty aIld volwltarlly Jejected the .tacked IiiDita of cover.,... r understand thlt my premiums will be reduced if I reject this cover.,... :J41~l1ro X jJt"'i'J,;~ IdIt. I . It of AMED INSURED roo NOT SIGN I COVERAGE IS REJECTED ABOVE,) t>e~~ J': ~{\l~ t Name 0 ht amed Insured QD'-l ).<(otf?'I'I II Policy Number lOver Please) . . . REJECTION OF UNDERINSURED MOTORIST PROTECTION Byalgnlbg this waiver I aID rejectiDg UDderi.ll.W'ed motoriot coverage ""der this policy, for my.elf and all rell. tives re.idillg in my household. Underi.llsured coverage protects me and relativealiving in my houHhold for lo..es aDd damages .uffered If injury Is caused by the negligence of I driver wbo doe. not bevo enough insurance to pay for all 104"'S and damages. I knowingly and volWltarDy reject this coverage. Dete x Signlture of FIRST NAMED INSURED Q Policy Number Print Name of First NalWd I..sured STOP I IF YOU HAVE REJECTED COVERAGE. DO NOT SIGN BELOW REDUCED LIMITS OF UNDERINSURED MOTORIST PROTECTION By .lflllDg this waiver, I am rejecting underinsured motori.t coverage limit. equal to my bodily injury liability Iimlta. I knowingly and voJuntarUy leleet UDderin.urod motori.t coverli' limlta lower than my bodily injury lia. b7ta ..,d oeIect tho limits checked below. , 16,000 per personlS 80,000 per accident , 26,000 per per80DII &0,000 per accident 1 &0,000 per persoDllloo,OOO per accident 1100,000 per perllOllll3oo,ooo per accident 1260,000 per per80DIISoo,ooo per accident _ 1300,000 per accident (Combined Single Llmit) f0."""1/.IIjJ,~ Sipa of FIRST NAMED INSURED (DO NOT SIGN n- COVERAGE IS REJECTED ABOVE,} \J ~V'\V'\l'-:, :J. WI"> \ ~ Print N..... of Firat Named Insured ]'\.1.\, \~ \ 11QO Date x QO~ ;dOl{'{ '('{ II Policy NlIIIlber UNDERINSURED COVERAGE LIMITS By algnlng thla waJver, I aID rejecting .tac:ked limlta of I1I3derinlured motoriot coverli' un<Ier the policy fOT my. MIl and memberl of my housebold I1I3der which the limlta of coverage avallable would be the sum of limits for each motor vehicle In.ured UDder the policy, Instesd the limit. of coverage that I am purchasing Iball be reduced \0 the limit. stated iD the policy, t knowingly and VObUltarUy reject the ltacked limit. of coverli'. I understand that my premium. wlIl be reduced If I reject thi. coverli', -J'A \'-<" ~ l'?7'cJ X JOA/X /llgn~ (fA{~AMED INSURED (DO NOT SIGN ~RAGE IS REJECTED ABOVE.) ~ ~~~2:)r~~ J~ Insured Q O~ J..1.0l..{C{'(t{ If oUcy Number UF-6985 lEd. 7190) lOver Please' "",*0fI~~' ~ W :T 6' ~ "'\'\ -- . , OUT OF POCKET EXPENSES OF . DENNIS AND DIXIE WALK 6/19 CD player and CD lost in the accident $130.00 Clothes cut off of Chelsea Walk $ 20.00 Gas $ 12.00 6/20 Gas (to and from Hershey) $12.00 Phone Card $10.00 6/21 Meals $10.00 Phone Card $10.00 6/22 Meals $20,00 Gas (to and from Hershey) $12.00 6/24 Gas (to and from Hershey) $19.00 Meals $10.00 6/25 Meals $ 3.50 Gas (to and from Hershey) $19.00 6/26 Was unable to do three jobs $265.00 Seasilver - multi vitamin with iron $100.00 2 month supply 7/9 Gas (to and from Hershey) $16.00 Meals $25.00 7/21 Reflex Gas $ 4.00 Appointment $25.00 Chlorophyll and Raspberry Leaf Tea $20.00 7/28 Reflex Gas $ 4.00 Appointment $25.00 TOTAL $771.50 bX~ , . : . PARENTS' JOINT TORT-FEASOR RELEASE & INDEMNITY AGREEMENT Page 1 of 2 KNOW ALL BY THESE PRESENTS: That the undersigned, individually and as legal parents and guardians ofChelsey Walk, a minor (hereinafter "Releasors"), for the sole consideration of Two Thousand and 00/100 ($2,000.00), receipt of which is hereby acknowledged, have remised, released, and forever discharged, and covenant to hold hannless, Michele Blevins, their heirs, administrators, executors, successors, agents, employees, subsidiaries, affiliates and assigns (hereinafter collectively referred to as "Releasees") from any and all claims, actions, and causes of action, including any claims or actions for wrongful death, or any survival actions, demands, liens, workers compensation liens, costs, expenses, compensations, claims for loss of services or loss of consortium, and all consequential, punitive and exemplary damages, or damages of any kind sustained or that may be hereafter sustained by the said minor, or on behalf of said minor, or by the undersigned, on account of or in any way arising out of an accident that occurred at or near Rt 34 and Pine Grove Rd., Cumberland County, PA, on or about 6/19/03, To procure the payment of the stated consideration, the Releasors hereby declare: that no representations about the nature and extent of the said injuries, disabilities or damages made by any physician, attorney or agent of Releasees, nor any representations regarding the nature and extent oflegalliability or financial responsibility of any of the parties released, have induced the Releasors to make this release and indemnity agreement; that this Release is entered into in consideration of all known and unknown injuries, disabilities and damages, and also the possibility that the injuries sustained may be permanent and progressive and recovery therefrom uncertain and indefinite, so that consequences not now anticipated may result from the said accident Should it appear that two or more persons or entities are jointly and severally liable in tort for the alleged injuries to the undersigned claimant, the consideration for this Release shall be received in reduction of the total damages recoverable against all the other tort-feasors to the extent of the pro rata shares of the said Releasees, and Releasors specifically reserve all claims and causes of action arising out of the above-mentioned accident against all other tort-feasors, In order to avoid inconvenience and expense to the released parties, in any action in which any of the Releasees are or may become a defendant or additional defendant or thiTd-party defendant with other alleged tort-feasors, it is further agreed by Releasors that any verdict rendered against the other parties not released herein, and any judgment entered on said verdict shall be in the amount of the verdict reduced by the pro rata share of those released herein. This provision is intended to obviate the necessity and expense of having any of the released parties herein remain parties on the record and obligated to participate at Releasees' expense in a trial merely for the purpose of detennining ifin fact any of the Releasees were a tort-feasor so as to ; JOINT TORT-FEASOR PARENTS' RELEASE & INDEMNITY AGREEMENT Page 2 of 2 . entitle the other tort-feasors to a pro rata reduction of any verdict, However, this provision in no way constitutes an admission of liability by the parties released herein, The payment made to the undersigned is upon Releasors warrant that no consideration has been received heretofore from any person, firm or corporation, nor has Releasors released heretofore any person, firm or corporation from any claim or liability for the said accident, and Releasors agree to hold harmless and indemnify said Releasees and insurer of any of the Releasees from any loss, expense, or liability growing out of any claim against Releasees for contribution of any alleged tort-feasor under the Uniform Contribution Among Tort-feasors Act. Further Releasors agree to indemnify and hold harmless said Releasees and any insurer of the Releasees from any additional sum of money that any of them may hereafter be compelled to pay on account of the injuries to said minor because of said accident. The Releasors understand(s) that the parties hereby released admit no liability of any sort by reason of said accident and that said accident and that said payment in compromise is made to terminate further controversy respecting all claims for damages that said minor or the undersigned have heretofore asserted or might personally or through personal representatives hereafter be asserted because of said accident. I have read this release and understand it. Signed: Witness date Dennis Walk date Witness date Dixie Walk date State of : County of: On this _ day of , 2-, before me personally appeared , to me known to be the person(s) who executed the foregoing instrument, and acknowledged this as a free act and deed. IN TESTIMONY WHEREOF, I have hereto subscribed my name and affixed my seal this day of ,2 My commission expires Notary Public Claim No.: 030917867 . I fthlhl +I It;?.; PARENTS.GUARDIAN RELEAse AND INDEMNITY AGREEMENT JIJ " ) !.n'1.J7?c' . FOR AND IN CONSIDERATION of the payment to me/us oflhe sum J of Eiohteen Thousand and xx/100 Dollars ($18.000), . the receipt of which is hereby acknowledged, l/we. thll undersigned. father and mother andlor guardian of Chelsev Walk a minor, do forever release. acqUI~ dl5charQ8 and covenant to hold harmless Frederick D. Rice heirs. suocessors and assigns of and from any and all actions. causes of action, claims, demands, damages, CO$ls. loss of seMces, expenses and compensation, on account of, or in any way growing out of any, and all known and unknown peroonal Injuries ano property damage which we may now 0/' hereafter have as the parents and/or guardian of said minor, and alSo all claims or rights of action for dllmages which the said minor has or may hereafter have, either before or after ~he has reached hiS/her mejOrity, resUlting or to result from a certain accldent which occurreo on or about the 19th day of >IU.M. ~ at or near Pine Grove Road and Carlisle RDad. Dickinson TwonshlD Cumberland County PA l/we furlher promise to bind myself/ourselves joinUy and sevllrally, my/our heirs. administrators and executors to repay to the said Frederick D. Rice heirs. successors and assigns any sum of maney, except the sum above mentioned that he/she/they may hereafter be compelled tD pay on behalf of said minor because of the said accident. It is further understood and agreed that this settlement Is the compromise of e dOUbtfUl and disputed claim, and that this payment is not to be construed 86 an admisaion of liability on the part of Frederick D. Rice by whDm liability Is expressly denied. l/we further slate that !/we have carefully read the foregoing release and know the contents thereof. and l/we sign the same S$ mylour own free act. ' , WITNESS In presllnce of Hand and seal this_ day of CAUTION: READ BEFORE SIGNING (SEAL) (SEAL) STATE OF .....'YLY.UrIA LAW IlIQUIlII u. 10 fNIlORIIlOU Of'TN: ro&.L.OWINO: .~ NMON WHO KNOW,"Gl.Y NoIQ WI1l'f fN'T'ENT TO DeIWJO ANY 1N8VAANCi: ~ ~ l)TNtR PlMON I"1L.!.I AN ~ ~ lNIUIWa: Ofll STATIiMINT OF CLAIM ~N1HG ANY MA'TENAl.L.Y ,AL.!I! ~ OR CONCSAI.8 FOR1ttE I'CJAF'O$i f$MlR.&tDlNGi ~ON CCNCiAMHG AN'( I'"AC1 MAT!flIIAl TH&ADO COMMlTSAPMUCUl.!NT' IN6UfWfCEACr, WHICH ISA OfIIlME AND SU80IiCTS SUCH PERSON TO CRIMtW. ANti CIVIL PINAl.lI!:S.. co ... p^ Westfield Croup'" . be",,,,... '"~ u",~ClI1 CI,J SS; COUNTY OF onl/lls day of to me personally, and who acknowledged the execution of the foregoing instrument as for the consideration set forth therein. My Commission Expires free act and deed, Notary Public (") ~ 2];'""'~ t>)i: j r --:::- .~~~ f J:> -~~ . C" :~.; -< ..... = = """ <- C. % I CD ~ :r~ rl1-:,..! ~'nFTi ,l}<:;' '..~:J ('''; ~~:, ~.;o (-jlTl ;; :":0 -< -0 :J: !';':' c:> - ... .. i RECEIVED JUN 09 Z005 r IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA DENNIS and DIXIE WALK, individually and as parents and natural guardians of CHELSEY WALK, a minor Plaintiffs v. MICHELE BLEVINS And FREDERICK D. RICE Defendants : Civil Action - Law : No. 2005-156 Civil Term : Jury Trial Demanded SCHEDULING ORDER o'clock A.Mj~. in Courtroom Number J -~ /~/ ~ AND NOW, this I "U day of merits ofthe within Petition is hereby set for the l4S J. t~ v't;dJ \"'\ o r~ 5 , 2005, a hearing on the day O~,I at -7 I FllED-DPFICE OF THE PROTHOI,!OTA,tW 2005 JUN 14 Pil 3: 59 r:u''"'''', ',' ',\11'\1 ...., i"i~_.:,.., "~ ,__,' l.,),../'-Ji'~ j I ","::-\;' 1r""I"lfI,l !,r I'C:.1 \1\':'1 L.lli-,i\-r\ DENNIS and DIXIE WALK, : IN THE COURT OF COMMON PLEAS OF Individually and as parents and natural : CUMBERLAND COUNTY, PENNSYLVANIA Guardians of CHELSEY WALK, a minor,: PLAINTIFFS V. MICHELE BLEVINS and FREDERICK D. RICE, DEFENDANTS : 05-0156 CIVIL TERM ORDER OF COURT AND NOW, this ~ day of July, 2005, IT IS ORDERED: (1) Approval of the settlement of this minor's claim for $20,000 for Chelsey Walk, a minor, born April 22, 1992, IS GRANTED. (2) From the settlement, a counsel fee of $5,000, IS APPROVED. (3) Costs of $385.53 are approved to be paid to plaintiffs' counsel for the filing fee. (4) $771.50 is allocated to Dennis Walk and Dixie Walk, the parents of Chelsey Walk, for out-of-pocket expenses. (5) The net proceeds of $13,842.97 shall be placed in a federally insured interest bearing investment in Community State Bank of Orbisonia, Saxton Branch, in the name of Chelsey Walk, born April 22, 1992. (6) The account shall contain the following notation: "NO WITHDRAWAL CAN BE MADE PRIOR TO CHELSEY WALK, BORN APRIL 22,1992, OBTAINING HER MAJORITY EXCEPT BY AN ORDER OF A COURT OF COMPETENT JURISDICTION." (7) Dennis Walk and Dixie Walk are authorized to sign any release necessary to effectuate this settlement, and to then settle and satisfy the docket. Herman A Gailey, Esquire For Plaintiffs ~ ~ :sal 'l_O'J.o!/ Q-. tr ~> ,..-;, U,JQ u"- n:f::~! ..!-....L- (:~~2 c,_ 0-- ---'ltJ O::j!: u.. o ~' 9 :c .c:<: b. f -':;.:-:; ("'~) ~~ .-.)~~ Hf ',!dJ : ',,:i.'1....- '-,,;. :::''\ <5 r- I -' => -, ,,-,, = = <-..l H .- ,,. ,- " , , - IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA DENNIS and DIXIE WALK, individually and as parents and natural guardians of CHELSEY WALK, a minor Plaintiffs Civil Action - Law v. No. 2005-156 Civil Term MICHELE BLEVINS And FREDERICK D. RICE Defendant Jury Trial Demanded PROOF OF DEPOSIT In accordance with the direction of the Honorable Edgar B. Bayley in his Order signed July 6, 2005, the attached letter is submitted of record as proof of deposit of the minor's settlement proceeds. Respectfully submitted: MARTZ & GAilEY llP Date: j'J pbmilib\~ B,;XO{ -?l-1t~ ~ Herman A. Gailey, III, Esquire 96 South George Street Suite 430 York, Pennsylvania 17401 (717) 852-8379 10 #: 31097 SAXTON OFFICE COmmUNIT... ~HnE 8J:1Nti OF ORBISoONIR Member Federal Deposit Insurance Corporation September 9, 2005 Martz & Gailey 96 South George St. Suite 430 York,PA 17401 Dear Mr. Gailey: It has been requested that I provide you with a letter detailing the account and referencing any restrictions for that account regarding Chelsey Walk. Account number 1160313 is set up as "Chelsey Walk, Minor Child". The amount deposited at the opening of this account on, September 8, 2005 was $13,842.97. The following restriction was placed upon said account:. I. No withdraw can be made prior to Chelsey Walk, born April 22, 1992, obtaining her majority except by an order of a court of competent jurisdiction. Sincerely, ~~~ Candace L Putt Customer Service Representative 620 MAIN STREET . SAXTON, PENNSYLVANIA 16678 . (814) 63S.9CSB (9272) FAX 635.2022 r-> = ,= <J' (/) 1"'1 " 1') CD ::2 -"- o -n :c::l -~- ..." n,p "pl>} ;:~;;'~, ~ ,\..: ...;, ::',:]~q 2Srn :::-t '" ~~ <-'" N ~.- IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA DENNIS and DIXIE WALK, individually and as parents and natural guardians of CHELSEY WALK, a minor Plaintiffs Civil Action - Law v, No. 2005-156 Civil Term MICHELE BLEVINS And FREDERICK D. RICE Defendants Jury Trial Demanded PRAECIPE TO SETTLE, DISCONTINUE & END Please mark the above-captioned action settled and satisfied. Please also issue a Certificate of Satisfaction. Respectfully submitted: MARTZ & GAILEY LLP Date: xt.ph 37. acoS' #-fIr;~@ Herman A. Gailey, III, Esquire 96 South George Street Suite 430 York, Pennsylvania 17401 (717) 852-8379 ill #: 31097 ............................................................................... I, U I,f2JL\ 12 . C,). 9, Prothonotary of the Court of Common Pleas of Cumberland County, Pennsylvania, do hereby certify that the above mentioned case settled, discontinued and ended on the :l9~ay of ~ 2005. Illfitness whereof I have hereunto set my hand and seal of said Court, this ;z:l!iday of ~, 2005, e~t~ Prothonotary ------------ "'" = c::;, c.n cn 1"?1 V 1" U) o --n :r~ m~ -oh1 -::00 (),). ~_ j 1..) ~;- "T, c5:!J :,>.C) (jm -( )-::>. :xl -< -n .-'.''''' ~c:~ w 0:> -